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Clinics, Volume: 68, Número: 9, Publicado: 2013
  • The risks of information in health care: do we need a new decision aid? Editorial

    Porzsolt, Franz; Thomaz, Tania Gouvêa; Constâncio, Thiago Inocêncio; Silva-Júnior, Aluisio Gomes da; Nóbrega, Antonio Claudio Lucas da
  • Preliminary analysis of knee stress in Full Extension Landing Clinical Sciences

    Makinejad, Majid Davoodi; Abu Osman, Noor Azuan; Wan Abas, Wan Abu Bakar; Bayat, Mehdi

    Resumo em Inglês:

    OBJECTIVE: This study provides an experimental and finite element analysis of knee-joint structure during extended-knee landing based on the extracted impact force, and it numerically identifies the contact pressure, stress distribution and possibility of bone-to-bone contact when a subject lands from a safe height. METHODS: The impact time and loads were measured via inverse dynamic analysis of free landing without knee flexion from three different heights (25, 50 and 75 cm), using five subjects with an average body mass index of 18.8. Three-dimensional data were developed from computed tomography scans and were reprocessed with modeling software before being imported and analyzed by finite element analysis software. The whole leg was considered to be a fixed middle-hinged structure, while impact loads were applied to the femur in an upward direction. RESULTS: Straight landing exerted an enormous amount of pressure on the knee joint as a result of the body's inability to utilize the lower extremity muscles, thereby maximizing the threat of injury when the load exceeds the height-safety threshold. CONCLUSIONS: The researchers conclude that extended-knee landing results in serious deformation of the meniscus and cartilage and increases the risk of bone-to-bone contact and serious knee injury when the load exceeds the threshold safety height. This risk is considerably greater than the risk of injury associated with walking downhill or flexion landing activities.
  • The skin tissue is adversely affected by TNF-alpha blockers in patients with chronic inflammatory arthritis: a 5-year prospective analysis Clinical Sciences

    Machado, Natalia P.; Reis Neto, Edgard Torres dos; Soares, Maria Roberta M.P.; Freitas, Daniele S.; Porro, Adriana; Ciconelli, Rozana M.; Pinheiro, Marcelo M.

    Resumo em Inglês:

    OBJECTIVE:We evaluated the incidence of and the main risk factors associated with cutaneous adverse events in patients with chronic inflammatory arthritis following anti-TNF-α therapy.METHODS:A total of 257 patients with active arthritis who were taking TNF-α blockers, including 158 patients with rheumatoid arthritis, 87 with ankylosing spondylitis and 12 with psoriatic arthritis, were enrolled in a 5-year prospective analysis. Patients with overlapping or other rheumatic diseases were excluded. Anthropometric, socioeconomic, demographic and clinical data were evaluated, including the Disease Activity Score-28, Bath Ankylosing Spondylitis Disease Activity Index and Psoriasis Area Severity Index. Skin conditions were evaluated by two dermatology experts, and in doubtful cases, skin lesion biopsies were performed. Associations between adverse cutaneous events and clinical, demographic and epidemiological variables were determined using the chi-square test, and logistic regression analyses were performed to identify risk factors. The significance level was set at p<0.05.RESULTS:After 60 months of follow-up, 71 adverse events (73.85/1000 patient-years) were observed, of which allergic and immune-mediated phenomena were the most frequent events, followed by infectious conditions involving bacterial (47.1%), parasitic (23.5%), fungal (20.6%) and viral (8.8%) agents.CONCLUSION:The skin is significantly affected by adverse reactions resulting from the use of TNF-α blockers, and the main risk factors for cutaneous events were advanced age, female sex, a diagnosis of rheumatoid arthritis, disease activity and the use of infliximab.
  • Magnetic resonance imaging and neuropsychological testing in the spectrum of normal aging Clinical Sciences

    Foss, Maria Paula; Diniz, Paula Rejane Beserra; Formigheri, Paulo; Salmon, Carlos Ernesto Garrido; Speciali, José Geraldo; Santos, Antônio Carlos

    Resumo em Inglês:

    OBJECTIVE: To understand the relationships between brain structures and function (behavior and cognition) in healthy aging. METHOD: The study group was composed of 56 healthy elderly subjects who underwent neuropsychological assessment and quantitative magnetic resonance imaging. Cluster analysis classified the cohort into two groups, one (cluster 1) in which the magnetic resonance imaging metrics were more preserved (mean age: 66.4 years) and another (cluster 2) with less preserved markers of healthy brain tissue (mean age: 75.4 years). RESULTS: The subjects in cluster 2 (older group) had worse indices of interference in the Stroop test compared with the subjects in cluster 1 (younger group). Therefore, a simple test such as the Stroop test could differentiate groups of younger and older subjects based on magnetic resonance imaging metrics. CONCLUSION: These results are in agreement with the inhibitory control hypotheses regarding cognitive aging and may also be important in the interpretation of studies with other clinical groups, such as patients with dementia and mild cognitive impairment.
  • Comparison of the direct fluorescence assay and real-time polymerase chain reaction for the detection of influenza virus A and B in immunocompromised patients Clinical Sciences

    Perosa, Ana Helena; Watanabe, Aripuanã S.A.; Guatura, Sandra B.; Silva, Ellen R.M.; Granato, Celso; Bellei, Nancy

    Resumo em Inglês:

    OBJECTIVE: This study evaluated the diagnostic performance of two methods for the detection of influenza virus in immunocompromised transplant patients. METHODS: A total of 475 respiratory samples, 236 from patients in a hematopoietic stem cell transplantation program and 239 from kidney transplant patients, were analyzed by a direct fluorescence assay and the Centers for Disease Control real-time polymerase chain reaction protocol for influenza A and B detection. RESULTS: Influenza detection using either method was 7.6% in the hematopoietic stem cell transplant group and 30.5% in the kidney transplant patient group. Influenza detection by real-time polymerase chain reaction yielded a higher positive rate compared with fluorescence than that reported by other studies, and this difference was more pronounced for influenza A. The fluorescence assay sensitivity, specificity, positive and negative predictive values, and kappa coefficient were 17.6%, 100%, 1, 0.83, and 0.256, respectively, and lower detection rates occurred in the kidney transplant patients. CONCLUSIONS: The real-time polymerase chain reaction performance and the associated turnaround time for a large number of samples support the choice of this method for use in different routine diagnostic settings and influenza surveillance in high-risk patients.
  • Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma Clinical Sciences

    Cerqueira Neto, Manoel Luiz de; Moura, Álvaro Vieira; Cerqueira, Telma Cristina Fontes; Aquim, Esperidião Elias; Reá-Neto, Álvaro; Oliveira, Mirella Cristine; da Silva Júnior, Walderi Monteiro; Santana-Filho, Valter J.; Herminia Scola, Rosana

    Resumo em Inglês:

    OBJECTIVE: To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables. METHOD: A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning. RESULTS: The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning. CONCLUSION: Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients.
  • Variation of the Anthropometric Index for pectus excavatum relative to age, race, and sex Clinical Sciences

    Rebeis, Eduardo Baldassari; Campos, Jose Ribas Milanez de; Moreira, Luis Felipe Pinho; Pastorino, Antonio Carlos; Pêgo-Fernandes, Paulo Manuel; Jatene, Fabio Biscegli

    Resumo em Inglês:

    OBJECTIVES: To determine possible variations in the Anthropometric Index for pectus excavatum relative to age, race, and sex in individuals free of thoracic wall deformities. METHODS: Between 2002 and 2012, 166 individuals with morphologically normal thoracic walls consented to have their chests and the perimeter of the lower third of the thorax measured according to the Anthropometric Index for pectus excavatum. The participant characteristics are presented (114 men and 52 women; 118 Caucasians and 48 people of African descent). RESULTS: Measurements of the Anthropometric Index for pectus excavatum were statistically significantly different between men and women (11-40 years old); however, no significant difference was found between Caucasians and people of African descent. For men, the index measurements were not significantly different across all of the age groups. For women, the index measurements were significantly lower for individuals aged 3 to 10 years old than for individuals aged 11 to 20 years old and 21 to 40 years old; however, no such difference was observed between women aged 11 to 20 years old and those aged 21 to 40 years old. CONCLUSION: In the sample, significant differences were observed between women aged 11 to 40 years old and the other age groups; however, there was no difference between Caucasian and people of African descent.
  • Thymosin ß4 expression in colorectal polyps and adenomas Clinical Sciences

    Nemolato, Sonia; Cabras, Tiziana; Restivo, Angelo; Zorcolo, Luigi; Di Felice, Eliana; Fanni, Daniela; Gerosa, Clara; Messana, Irene; Castagnola, Massimo; Faa, Gavino; Casula, Giuseppe

    Resumo em Inglês:

    OBJECTIVE: Thymosin beta 4 (Tβ4) is a ubiquitous peptide that plays pivotal roles in the cytoskeletal system and in cell differentiation. Recently, a role for Tβ4 has been proposed in experimental and human carcinogenesis, including gastrointestinal cancer. This study was aimed at evaluating the relationship between Tβ4 immunoreactivity and the initial steps of carcinogenesis. METHODS: In total, 60 intestinal biopsies, including 10 hyperplastic polyps, 10 sessile serrated adenomas/polyps, 15 colorectal adenomas with low-grade dysplasia, 15 adenomas with high-grade dysplasia, 15 adenocarcinomas and 10 samples of normal colon mucosa, were analyzed for Tβ4 expression by immunohistochemistry. RESULTS: Weak cytoplasmic reactivity for Tβ4 was detected in the normal colon mucosa. No reactivity for Tβ4 was found in hyperplastic and sessile serrated polyps/adenomas. Tβ4 expression was observed in 10/15 colorectal adenocarcinomas. In adenomas with low-grade dysplasia, Tβ4 immunoreactivity was mainly detected in dysplastic glands but was absent in hyperplastic glands. Tβ4 immunoreactivity was characterized by spot-like perinuclear staining. In high-grade dysplastic polyps, immunostaining for Tβ4 appeared diffuse throughout the entire cytoplasm of dysplastic cells. Spot-like perinuclear reactivity was detected in adenocarcinoma tumor cells. CONCLUSIONS: Our study shows for the first time that Tβ4 is expressed during different steps of colon carcinogenesis. The shift of Tβ4 immunolocalization from low-grade to high-grade dysplastic glands suggests a role for Tβ4 in colorectal carcinogenesis. However, the real meaning of Tβ4 reactivity in dysplastic intestinal epithelium remains unknown.
  • Right ventricular involvement in anterior myocardial infarction: a tissue Doppler-derived strain and strain rate study Clinical Sciences

    Sonmez, Osman; Kayrak, Mehmet; Altunbas, Gokhan; Abdulhalikov, Turyan; Alihanoglu, Yusuf; Bacaksiz, Ahmet; Ozdemir, Kurtulus; Gok, Hasan

    Resumo em Inglês:

    OBJECTIVE: Strain and strain rate imaging is currently the most popular echocardiographic technique that reveals subclinical myocardial damage. There are currently no available data on this imaging method with regard to assessing right ventricular involvement in anterior myocardial infarction. Therefore, we aimed to evaluate right ventricular regional functions using a derived strain and strain rate imaging tissue Doppler method in patients who were successfully treated for their first anterior myocardial infarction. METHODS: The patient group was composed of 44 patients who had experienced their first anterior myocardial infarction and had undergone successful percutaneous coronary intervention. Twenty patients were selected for the control group. The right ventricular myocardial samplings were performed in three regions: the basal, mid, and apical segments of the lateral wall. The individual myocardial velocity, strain, and strain rate values of each basal, mid, and apical segment were obtained. RESULTS: The right ventricular myocardial velocities of the patient group were significantly decreased with respect to all three velocities in the control group. The strain and strain rate values of the right mid and apical ventricular segments in the patient group were significantly lower than those of the control group (excluding the right ventricular basal strain and strain rate). In addition, changes in the right ventricular mean strain and strain rate values were significant. CONCLUSION: Right ventricular involvement following anterior myocardial infarction can be assessed using tissue Doppler based strain and strain rate
  • Ulinastatin attenuates oxidation, inflammation and neural apoptosis in the cerebral cortex of adult rats with ventricular fibrillation after cardiopulmonary resuscitation Basic Researches

    Hu, Chun Lin; Xia, Jin Ming; Cai, Jie; Li, Xin; Liao, Xiao Xing; Li, Hui; Zhan, Hong; Dai, Gang; Jing, Xiao Li

    Resumo em Inglês:

    OBJECTIVE: The role of Ulinastatin in neuronal injury after cardiopulmonary resuscitation has not been elucidated. We aim to evaluate the effects of Ulinastatin on inflammation, oxidation, and neuronal injury in the cerebral cortex after cardiopulmonary resuscitation. METHODS: Ventricular fibrillation was induced in 76 adult male Wistar rats for 6 min, after which cardiopulmonary resuscitation was initiated. After spontaneous circulation returned, the rats were split into two groups: the Ulinastatin 100,000 unit/kg group or the PBS-treated control group. Blood and cerebral cortex samples were obtained and compared at 2, 4, and 8 h after return of spontaneous circulation. The protein levels of tumor necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) were assayed using an enzyme-linked immunosorbent assay, and mRNA levels were quantified via real-time polymerase chain reaction. Myeloperoxidase and Malondialdehyde were measured by spectrophotometry. The translocation of nuclear factor-κB p65 was assayed by Western blot. The viable and apoptotic neurons were detected by Nissl and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL). RESULTS: Ulinastatin treatment decreased plasma levels of TNF-α and IL-6, expression of mRNA, and Myeloperoxidase and Malondialdehyde in the cerebral cortex. In addition, Ulinastatin attenuated the translocation of nuclear factor-κB p65 at 2, 4, and 8 hours after the return of spontaneous circulation. Ulinastatin increased the number of living neurons and decreased TUNEL-positive neuron numbers in the cortex at 72 h after the return of spontaneous circulation. CONCLUSIONS: Ulinastatin preserved neuronal survival and inhibited neuron apoptosis after the return of spontaneous circulation in Wistar rats via attenuation of the oxidative stress response and translocation of nuclear factor-κB p65 in the cortex. In addition, Ulinastatin decreased the production of TNF-α, IL-6, Myeloperoxidase, and Malondialdehyde.
  • Effect of hyperbaric oxygen therapy combined with autologous platelet concentrate applied in rabbit fibula fraction healing Basic Researches

    Neves, Paulo César Fagundes; Abib, Simone de Campos Vieira; Neves, Rogério Fagundes; Pircchio, Oronzo; Saad, Karen Ruggeri; Saad, Paulo Fernandes; Simões, Ricardo Santos; Moreira, Marcia Bento; Laurino, Cristiano Frota de Souza

    Resumo em Inglês:

    OBJECTIVES: The purpose is to study the effects of hyperbaric oxygen therapy and autologous platelet concentrates in healing the fibula bone of rabbits after induced fractures. METHODS: A total of 128 male New Zealand albino rabbits, between 6-8 months old, were subjected to a total osteotomy of the proximal portion of the right fibula. After surgery, the animals were divided into four groups (n = 32 each): control group, in which animals were subjected to osteotomy; autologous platelet concentrate group, in which animals were subjected to osteotomy and autologous platelet concentrate applied at the fracture site; hyperbaric oxygen group, in which animals were subjected to osteotomy and 9 consecutive daily hyperbaric oxygen therapy sessions; and autologous platelet concentrate and hyperbaric oxygen group, in which animals were subjected to osteotomy, autologous platelet concentrate applied at the fracture site, and 9 consecutive daily hyperbaric oxygen therapy sessions. Each group was divided into 4 subgroups according to a pre-determined euthanasia time points: 2, 4, 6, and 8 weeks postoperative. After euthanasia at a specific time point, the fibula containing the osseous callus was prepared histologically and stained with hematoxylin and eosin or picrosirius red. RESULTS: Autologous platelet concentrates and hyperbaric oxygen therapy, applied together or separately, increased the rate of bone healing compared with the control group. CONCLUSION: Hyperbaric oxygen therapy and autologous platelet concentrate combined increased the rate of bone healing in this experimental model.
  • Effects of ovariectomy and resistance training on oxidative stress markers in the rat liver Basic Researches

    Rodrigues, Maria Fernanda Cury; Stotzer, Uliana Sbeguen; Domingos, Mateus Moraes; Deminice, Rafael; Shiguemoto, Gilberto Eiji; Tomaz, Luciane Magri; Sousa, Nuno Manuel Frade de; Ferreira, Fabiano Candido; Leite, Richard Diego; Selistre-de-Araújo, Heloisa Sobreiro; Jordão-Júnior, Alceu Afonso; Baldissera, Vilmar; Perez, Sérgio Eduardo de Andrade

    Resumo em Inglês:

    OBJECTIVE: The objective of this study was to assess the effects of resistance training on oxidative stress markers in the livers of ovariectomized rats. METHOD: Adult Sprague-Dawley rats were divided into the following four groups (n = 8 per group): sham-operated sedentary, ovariectomized sedentary, sham-operated resistance training, and ovariectomized resistance training. During the resistance training period, the animals climbed a 1.1-m vertical ladder with weights attached to their tails; the sessions were conducted 3 times per week, with 4-9 climbs and 8-12 dynamic movements per climb. The oxidative stress was assessed by measuring the levels of reduced glutathione and oxidized glutathione, the enzymatic activity of catalase and superoxide dismutase, lipid peroxidation, vitamin E concentrations, and the gene expression of glutathione peroxidase. RESULTS: The results showed significant reductions in the reduced glutathione/oxidized glutathione ratio (4.11±0.65 nmol/g tec), vitamin E concentration (55.36±11.11 nmol/g), and gene expression of glutathione peroxidase (0.49±0.16 arbitrary units) in the livers of ovariectomized rats compared with the livers of unovariectomized animals (5.71±0.71 nmol/g tec, 100.14±10.99 nmol/g, and 1.09±0.54 arbitrary units, respectively). Moreover, resistance training for 10 weeks was not able to reduce the oxidative stress in the livers of ovariectomized rats and induced negative changes in the hepatic anti-oxidative/oxidative balance. CONCLUSION: Our findings indicate that the resistance training program used in this study was not able to attenuate the hepatic oxidative damage caused by ovariectomy and increased the hepatic oxidative stress.
  • Phytoestrogen α-zearalanol ameliorates memory impairment and neuronal DNA oxidation in ovariectomized mice Basic Researches

    Dong, Yilong; Wang, Yanmei; Liu, Yanyong; Yang, Nan; Zuo, Pingping

    Resumo em Inglês:

    OBJECTIVE: The aim of this study was to evaluate the effect of a novel phytoestrogen, α-Zearalanol, on Alzheimer's disease-related memory impairment and neuronal oxidation in ovariectomized mice. METHODS: Female C57/BL6 mice were ovariectomized or received sham operations and treatment with equivalent doses of 17β-estradiol or α-Zearalanol for 8 weeks. Their spatial learning and memory were analyzed using the Morris water maze test. The antioxidant enzyme activities and reactive oxygen species generation, neuronal DNA oxidation, and MutT homolog 1 expression in the hippocampus were measured. RESULTS: Treatment with 17β-estradiol or α-Zearalanol significantly improved spatial learning and memory performance in ovariectomized mice. In addition, 17β-estradiol and α-Zearalanol attenuated the decrease in antioxidant enzyme activities and increased reactive oxygen species production in ovariectomized mice. The findings indicated a significant elevation in hippocampi neuronal DNA oxidation and reduction in MutT homolog 1 expression in estrogen-deficient mice, but supplementation with 17β-estradiol or α-Zearalanol efficaciously ameliorated this situation. CONCLUSION: These results demonstrate that α-Zearalanol is potentially beneficial for improving memory impairments and neuronal oxidation damage in a manner similar to that of 17β-estradiol. Therefore, the compound may be a potential therapeutic agent that can ameliorate neurodegenerative disorders related to estrogen deficiency.
  • The effect of school-based physical activity interventions on body mass index: a meta-analysis of randomized trials Reviews

    Guerra, Paulo Henrique; Nobre, Moacyr Roberto Cuce; Silveira, Jonas Augusto Cardoso da; Taddei, José Augusto de Aguiar Carrazedo

    Resumo em Inglês:

    This study reviewed the effectiveness of school-based physical activity interventions aimed at reducing overweight, obesity and hypertension in children. We searched 14 databases and analyzed studies published between April 2009 and September 2012. Only randomized controlled trials performed at the school level that included elements of physical activity but did not include nutritional co-interventions were analyzed. Studies were assessed by two recommended tools (EPHPP and GRADE), and the standardized mean differences with 95% confidence intervals were collected for a random-effect meta-analysis. A total of 12 papers were included in the meta-analysis, and these were divided according to three outcomes: body mass index (11 trials, n = 4,273, −0.02, 95% CI: −0.13 to 0.17, p = 0.8); body weight (5 trials, n = 1,330, −0.07, 95% CI: −0.18 to 0.04, p = 0.2); and blood pressure (6 trials, n = 1,549), including systolic (0.11, 95% CI: −0.10 to 0.31, p = 0.3) and diastolic pressure (−0.00, 95% CI: −0.10 to 0.10, p = 0.9). This meta-analysis of data from 11 randomized, school-based physical activity interventions suggests that, regardless of the potential benefits of physical activity in the school environment, the interventions did not have a statistically significant effect. However, it is difficult to generalize from these results because the duration, intensity and type of physical activity used in the interventions varied greatly.
  • Assessment of depression in medical patients: A systematic review of the utility of the Beck Depression Inventory-II Reviews

    Wang, Yuan-Pang; Gorenstein, Clarice

    Resumo em Inglês:

    To perform a systematic review of the utility of the Beck Depression Inventory for detecting depression in medical settings, this article focuses on the revised version of the scale (Beck Depression Inventory-II), which was reformulated according to the DSM-IV criteria for major depression. We examined relevant investigations with the Beck Depression Inventory-II for measuring depression in medical settings to provide guidelines for practicing clinicians. Considering the inclusion and exclusion criteria seventy articles were retained. Validation studies of the Beck Depression Inventory-II, in both primary care and hospital settings, were found for clinics of cardiology, neurology, obstetrics, brain injury, nephrology, chronic pain, chronic fatigue, oncology, and infectious disease. The Beck Depression Inventory-II showed high reliability and good correlation with measures of depression and anxiety. Its threshold for detecting depression varied according to the type of patients, suggesting the need for adjusted cut-off points. The somatic and cognitive-affective dimension described the latent structure of the instrument. The Beck Depression Inventory-II can be easily adapted in most clinical conditions for detecting major depression and recommending an appropriate intervention. Although this scale represents a sound path for detecting depression in patients with medical conditions, the clinician should seek evidence for how to interpret the score before using the Beck Depression Inventory-II to make clinical decisions.
  • Increased red cell distribution width in patients with slow coronary flow Readers Opinions

    Balta, Sevket; Kucuk, Ugur; Arslan, Zekeriya; Unlu, Murat; Demirkol, Sait; Celik, Turgay
  • Authors' comments on: Higher red cell distribution width in patients with slow coronary flow Readers Opinions

    Luo, Song-Hui; Li, Jian-Jun
  • The Yin and Yang of dyspnea in the emergency department: heart failure or COPD? Readers Opinions

    Canpolat, UĞur; Turak, Osman; TopaloĞlu, Serkan; Aras, Dursun; AydoĞdu, Sinan
  • Is there a relationship between left atrium size and p-wave dispersion in patients with lichen planus? Readers Opinions

    Sen, Bilge Bulbul; Rifaioglu, Emine Nur; Erayman, Ali; Sen, Nihat
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