Evaluation of the Sheffield score, clinical characteristics, and the therapeutic approach in children with upper gastrointestinal system bleeding

OBJECTIVE

Unlike adults, there is no valid and reliable scoring system for upper gastrointestinal system bleeding (UGB) in children. The Sheffield scoring system, which is awaiting confirmation, is the single scoring system which can be predictive for children who require high-risk, endoscopic therapeutic intervention. The aim of this study was to evaluate the efficacy of the Sheffield scoring system, the clinical characteristics of patients, and the treatments applied.

PATIENTS AND METHODS

Evaluation was made of a total of 86 children with UGB who underwent esophagogastroduodenoscopy and for whom the Sheffield score was calculated. The decision for therapeutic intervention was made according to the clinical status independently of the score. The demographic data of the patients, clinical symptoms and findings, risk factors, and treatments were examined retrospectively.

RESULTS

The Sheffield score was calculated as ≤8 in 67.4% of the patients and >8 in 32.6%. Endoscopic hemostatic intervention was applied to 15.1% of the patients. The rate of therapeutic endoscopy was significantly high in the high-score group. In 11 patients with Sheffield score >8, the bleeding was brought under control with octreotide treatment administered before endoscopy and no invasive intervention was applied. The sensitivity and specificity of the Sheffield score were determined to be at a good level in the prediction of the requirement for therapeutic endoscopy and octreotide treatment.

CONCLUSIONS

The Sheffield score can reliably predict the need for endoscopic treatment with high sensitivity and specificity. In children with a high score, the need for an invasive intervention can be reduced with the administration of vasoactive treatment before esophagogastroduodenoscopy. The Sheffield score can thus be of guidance in the determination of the need for vasoactive treatment.

Tracheomediastinal emphysema after tracheostomy in a post-COVID-19 patient: a case report

OBJECTIVE

There are no reports of tracheomediastinal fistula development after tracheostomy.

CASE REPORT

A 72-year-old female patient with post acute COVID-19 was transferred to our intensive care unit. After two unsuccessful weaning attempts, a tracheostomy was performed at hospitalization on day 32. The patient's body mass index was 35 kg/m2 and she had a narrow neck anatomy. A percutaneous tracheostomy was performed using the Griggs method without any problems. Pneumothorax, pneumomediastinum, subcutaneous emphysema, and hemorrhage were not observed. Twenty-two days after the tracheostomy, the patient developed subcutaneous emphysema and experienced a sudden decrease in oxygen saturation. Bedside anterior-posterior chest X-ray did not detect pneumothorax and a tracheoesophageal fistula was found via esophageal endoscopy. A tracheomediastinal fistula was observed just below the cannula distal end via computed tomography.

CONCLUSIONS

There are multiple reasons why a tracheomediastinal fistula could develop after tracheostomy. Therefore, this condition should be considered in cases of sudden subcutaneous emphysema and oxygen deterioration following tracheostomy.

Determination of dosimetric properties of MgO doped natural amethyst samples

In this paper, the thermoluminescence (TL) dosimetric characteristics of MgO doped natural amethyst samples (Mg-NA) are presented. The morphologies and chemical structures of the powder form samples were identified using XRD, FTIR, SEM, SEM mapping and EDX. Comparison of the TL intensities showed that 10wt% Mg-NA was nearly 150 times more sensitive than undoped amethyst and the main dosimetric properties proved that 10wt% Mg-NA may be a promising phosphor for clinical and radiotherapy purposes.

Sonographic Findings of Median Nerve and Prevalence of Carpal Tunnel Syndrome in Computer Mouse Users

The purpose of this study was to evaluate the median nerve sonographically and estimate the prevalence of carpal tunnel syndrome (CTS) in computer mouse users. Forty-nine right wrists of 49 employees who had used a computer mouse were included in the study. Thirty-three right wrists of 33 non-mouse user employees were studied as a control group. Both the mouse user and non-mouse user employees underwent sonography and electromyography (EMG). Axial sonograms of the median nerve were obtained proximally, in the middle and distally in the carpal tunnel. At each level, flattening ratio and the cross-sectional area of the median nerve were calculated. We found no significant difference in any parameters between mouse users and control group ( p>0.05). However, when we compared mouse users according to the presence of pain, there was a significant increase in the cross-sectional area of the median nerve proximally in the mouse users having pain ( p<0.05). Of all mouse users, eight (16.3%) were diagnosed as sensory CTS, four (8.2%) as motor CTS by EMG. We also found that four (50%) CTS patients had a proximal cross-sectional area of median nerve exceeding 10 mm2 and five (62.5%) had a distal flattening ratio over three. Prolonged use of a mouse may pose an occupational risk for employees. Sonography can serve as an initial step in symptomatic patients for diagnosis of CTS.

A new activator strontium for magnesium tetraborate: PL and TL studies

Strontium was used for the first time as an activator agent for magnesium tetraborate (MBO) and photoluminescence (PL) and thermoluminescence (TL) properties were determined using a spectrophotometer and a TL reader, respectively. The results proved that 0.25wt% Sr ratio played an important role in prolonging the afterglow and the phosphor gave the main TL peak with the highest intensity at 200°C like an ideal case. Therefore, it is worthwhile to carry out continuous and systematic research on it.

Effect of agomelatine on adult hippocampus apoptosis and neurogenesis using the stress model of rats

Agomelatine (AG) is an agonist of melatonin receptors and an antagonist of the 5-HT2C-receptor subtype. The chronobiotic properties of AG are of significant interest due to the disorganization of internal rhythms, which might play a role in the pathophysiology of depression. The present study was designed to assess the effects of the antidepressant-like activity of AG, a new antidepressant drug, on adult neurogenesis and apoptosis using stress-exposed rat brains. Over the period of 1 week, the rats were exposed to light stress twice a day for 1h. After a period of 1 week, the rats were given AG treatment at a dose of either 10mg/kg or 40mg/kg for 15 days. The animals were then scarified, and the obtained tissue sections were stained with immuno-histochemical anti-BrdU, Caspase-3, and Bcl-2 antibodies. Serum brain-derived neurotrophic factor (BDNF) concentrations were measured biochemically using a BDNF Elisa kit. Biochemical BDNF analysis revealed a high concentration of BDNF in the serum of the stress-exposed group, but the concentrations of BDNF were much lower those of the AG-treated groups. Immuno-histochemical analysis revealed that AG treatment decreased the BrdU-positive and Bcl-2-positive cell densities and increased the Caspase-3-positive cell density in the hippocampus of stress-induced rats as compared to those of the stress group. The results of the study demonstrated that AG treatment ameliorated the hippocampal apoptotic cells and increased hippocampal neurogenesis. These results also strengthen the possible relationship between depression and adult neurogenesis, which must be studied further.

Visual Hallucinations in an Old Patient after Cataract Surgery and Treatment

Sensory visual pathologies, accompanying simple or complex visual hallucinations that occur in visually-impaired individuals due to ophthalmologic or brain pathologies related to visual pathways in patients without mental disorders, are defined as Charles Bonnet syndrome. Between 10% and 60% of the patients having age-related eye diseases involving retina, cornea and the lens, commonly with macular degeneration experience complex visual hallucinations depending on the severity of visual problems. The neurophysiology of the visual hallucinations in Charles Bonnet Syndrome is not clearly known, and they may differ in content and severity over time. In differential diagnoses of Charles Bonnet Syndrome, many aetiologies (drugs, uraemia, exposure to toxic materials, neurodegenerative and psychiatric conditions) need to be ruled out. In the treatment of Charles Bonnet syndrome, first the management of the reason of visual loss should be clarified if possible. If needed, neuroleptics, anticonvulsants, antidepressants, benzodiazepines, cognitive enhancer agents such as cholinesterase inhibitors can be used also. In this case, an 83-year-old female patient experiencing visual hallucinations as burning candles in both eyes' visual field after left eye cataract surgery, treated with 0.5 milligram/day risperidone will be presented.

Caregiver Burden, Anxiety, Depression, and Sleep Quality Differences in Caregivers of Hemodialysis Patients Compared With Renal Transplant Patients

BACKGROUND

We compared the caregivers of hemodialysis (HD) patients and caregivers of patients with renal transplantation (Tx) in terms of anxiety, depression, sleep quality, and caregiver burden. We believe that caregivers of HD have more difficult conditions than caregivers of the patients with Tx.

METHODS

This cross-sectional study analyzed the psychological status of caregivers of Tx patients compared with those of HD patients with using the Hospital Anxiety and Depression Scale, Zarit Burden Interview, and Pittsburg Sleep Quality Indexes. We recruited 133 caregivers-65 caregivers in the Tx group and 68 in the HD group.

RESULTS

Mean age was 43.1 ± 8.5 years. The age, sex, income level, and education level were similar between the 2 groups. Caregivers in the HD group had significantly higher rates of anxiety and depression compared with the Tx group (P = .007 and P < .001, respectively). Good sleep quality rates for caregivers in the Tx group and caregivers in the HD group were 92% (n = 60) and 63% (n = 43), respectively. Poor sleep quality was significantly higher in caregivers in the HD group compared with caregivers in the Tx group (P < .001). Caregiver burden scores were significantly higher for caregivers in the HD group compared with caregivers in the Tx group (P < .001).

CONCLUSIONS

We suggest that Tx is the more appropriate renal replacement therapy for caregivers who undertake the care of patients with end-stage renal disease and chronic kidney disease.

Female attempted suicide patients with low HDL levels are at higher risk of suicide re-attempt within the subsequent year: a clinical cohort study

Our aims were, to clarify the blood lipid differences [Total serum cholesterol (TC), High-density lipoprotein (HDL), Low density lipoprotein (LDL), Triglyceride (TG)] between female patients who had attempted suicide and controls and to determine whether we could use the patients׳ initial lipid profiles to predict suicide re-attempt within the subsequent year. A total of 284 participants (110 cases and 174 controls) were recruited, with no differences in body mass index, age, blood sampling time and gender. Blood samples were collected from all participants for serum lipid profiles and assayed in an auto-analyzer. We divided the suicide re-attempter group into suicide attempters in the subsequent year (SSY) and suicide attempters after the subsequent year (SASY). The TC, LDL, and TG levels were significantly lower in the suicidal group than in the control group. HDL was significantly higher in the suicidal group than in the control group. Low TG (<70mg/dL) (OR (odds ratio)=12.8; 95% CI (confidence interval)=5.4-30.5; p<0.0001)and low LDL/HDL (<1.8) (OR=4.1; 95% CI=1.8-9.3; p=0.001) were significantly associated with a current suicide attempt. HDL levels in the SSY (41.5±4.5mg/dL) were lower than in the non-suicide attempters group (NSA) (50.9±10.3mg/dL) and SASY (58.7±12.8mg/dL)(d.f.=2, F=5.2, p=0.007). Serum HDL level may be a potential candidate predictor for the future risk of suicidality.

Ultra-structural changes and apoptotic activity in cerebellum of post-menopausal-diabetic rats: a histochemical and ultra-structural study

Diabetes mellitus (DM) is one of the most common and chronic diseases, especially in post-menopausal periods. Neuro-degeneration occurs more frequently in post-menopausal diabetics. Therefore, we investigated ovariectomized rats cerebellar cortex response to the estradiol deficiency and hyperglycemia. For the ovariectomy, the rats were bilaterally ovariectomized, and then DM induced by a single dose of Alloxan monohydrate injection in ovariectomy or/and diabetic groups. During light and electron microscopic examination, degenerated Purkinje cells membrane, swollen organelles, degenerated mitochondria, edema formation and vacuolization were seen in the ovariectomy and ovariectomy-diabetic groups sections. In addition, increased apoptotic activity was observed in the ovariectomy and ovariectomy-diabetic groups compared to the control group. We demonstrated that estradiol and insulin deficiency can affect the cerebellar cortex, which support the hypothesis that the execution of neuronal damages in post-menopausal diabetics. Also, diabetes and menopause are major risks factors for many disorders including nervous system and the number of post-menopausal-diabetics are increasing world-wide.

Long-term outcomes of pars plana vitrectomy without internal limiting membrane peeling for optic disc pit maculopathy

PURPOSE

To evaluate the results of surgical treatment of maculopathy secondary to congenital optic pit anomaly with pars plana vitrectomy (PPV), endolaser to the temporal edge of the optic disc and C3F8 tamponade without internal limiting membrane (ILM) peeling.

PATIENTS AND METHODS

Thirteen eyes of 12 patients with serous macular detachment and/or macular retinoschisis secondary to congenital optic disc pit (ODP) were included in the study. All eyes underwent PPV, posterior hyaloid removal, endolaser photocoagulation on the temporal margin of the optic disc and 12% C3F8 gas tamponade. Anatomic success and functional outcome determined retrospectively by optical coherence tomography and measurement of best corrected visual acuity (BCVA), respectively were the main outcome parameters.

RESULTS

Two lines or more improvement in BCVA was obtained in 11 eyes and 6 of these eyes had 20/40 or better BCVA at the final visit. Subretinal or intraretinal fluid was completely resorbed postoperatively in 12 eyes but a little intraretinal fluid persisted in one eye at the 16-month follow-up. Better visual improvement was observed in patients treated by earlier surgical intervention.

CONCLUSION

PPV, C3F8 gas tamponade and endolaser to the optic disc margin without ILM peeling may yield favourable results in the treatment of ODP maculopathy.

Remifentanil without muscle relaxants for intubation in microlaryngoscopy: a double blind randomised clinical trial

OBJECTIVES

We aimed to compare the effect of remifentanil without muscle relaxant with succinylcholine for intubation in microlaryngoscopy.

PATIENTS AND METHODS

Eighty patients were randomly divided into two groups: Group R (n=40) and S (n=40) received remifentanil 4 µg/kg intravenously or 1 µg/kg respectively. Anesthesia was induced with 2 mg/kg propofol in both groups. Intubation was performed after bolus administration of 10 ml saline as a placebo or 1 mg/kg of succinylcholine in Group R and S respectively. Remifentanil infusion was initiated at 0.025 μg/kg in each groups.

RESULTS

Intubation conditions were similar in both groups. The mean arterial pressure (MAP) values at post-induction period were significantly lower in the Group S than in the Group R (p = 0.001). The requirement for ephedrine in Group R was found to be significantly lower than Group S (p = 0.023). Recovery times were significantly shorter (p = 0.001) and recovery scores were significantly higher (p = 0.021) in Group R. Time to patient could respond to commands was significantly longer in the Group S (p = 0.001). The surgeon's satisfaction score was significantly higher in Group R (p = 0.001).

CONCLUSIONS

It was concluded that remifentanil without muscle relaxants provides similar intubating conditions as that provided by succinylcholine, and remifentanil is superior to succinylcholine with regard to haemodynamic stability and recovery duration.

Effects of preoperative iron deficiency on transfusion requirements in liver transplantation recipients: a prospective observational study

The aims of this study were to determine the frequency of preoperative iron deficiency in adult living donor liver transplantation patients and to investigate its relationship with the need for intraoperative transfusion. Between September 1, 2011, and June 1, 2012, 103 patients scheduled for liver transplantation were included in this prospective study. Patients were divided into 2 groups according to baseline iron status: an iron-deficient group and a non deficient (normal iron profile) group. Iron deficiency was assessed on the basis of several parameters, including transferrin saturation, levels of ferritin, soluble transferrin receptor, C-reactive protein, and peripheral blood smear. Preoperative iron deficiency was diagnosed in 62 patients. Preoperative iron deficiency was associated with low preoperative hemoglobin levels (P = .01) and a high rate of intraoperative transfusion (P < .0001). Preoperative iron deficiency is prognostic factor for predicting intraoperative transfusion requirements. These findings have important implications for transfusion practices for liver transplant recipients.

The effects of ephedrine on maternal hypothermia in caesarean sections: a double blind randomized clinical trial

BACKGROUND

The purpose of the study was to investigate the effect of bolus and the combination of bolus and infusion of ephedrine on maternal hypothermia which are used for treating maternal hypotension under spinal anaesthesia.

PATIENTS AND METHODS

110 ASA I-II patients who developed maternal hypotension were included into the study. Spinal anaesthesia was performed with 12.5 mg heavy bupivacaine + 15 µg fentanyl. Group I: Ephedrine bolus 5 mg plus ephedrine infusion, Group B: Ephedrine bolus 5 mg plus normal saline infusion. The systolic blood pressure was allowed to range between 20% from baseline values. Ephedrine solution infusion started after hypotension occurred (0.5 mg/minute). The body temperature under 35.5°C was accepted as hypothermia. The newborns' rectal temperature was measured. Moreover, the Apgar scores, umbilical vein-arterial blood gas and acid-base status were evaluated.

RESULTS

In Group I, the body core temperatures which were measured at 9, 18, 33, and 39th minutes were significantly higher than Group B (p < 0.05). The prevalence of maternal hypothermia in Group I was significantly lower than the Group B, which were as 65.5% (36/55) and 85.5% (47/55), respectively (p < 0.05). In Group I, the newborn rectal temperatures and the total dose of ephedrine were significantly higher than Group B (p < 0.05). In Group I, the systolic and mean blood pressures were higher than Group B (p < 0.05).

CONCLUSIONS

As a result, we found that combined bolus and infusion of ephedrine for treating maternal hypotension prevents maternal and neonatal hypothermia during caesarean section under spinal anaesthesia compared to bolus administrations alone.

Mirtazapine protects against cisplatin-induced oxidative stress and DNA damage in the rat brain

AIM

Cisplatin chemotherapy is associated with neurotoxicity, and oxidative stress might play an important role in the pathogenesis. Mirtazapine may be a preventative agent via its less-known antioxidant properties. The aim of this study was to examine the potential chemoprotective effects of mirtazapine against cisplatin-induced oxidative stress and DNA damage.

METHODS

Twenty-four rats were divided equally into four groups: control; cisplatin (10 mg/kg i.p.); cisplatin plus mirtazapine (10-30 mg/kg, respectively i.p and p.o.); and mirtazapine (30 mg/kg p.o.). The rats were killed at the end of the 14th day of treatment. Brain tissue was examined with regard to antioxidant/oxidant biochemical parameters.

RESULTS

Although glutathione (tGSH) and nitric oxide (NO) end product mean scores were found to be statistically higher in the control group when compared with the cisplatin group (72.44% and 61.99% percentage change [PC], respectively), malondialdehyde (MDA), myeloperoxidase (MPO), and 8-hydroxyguanine (8-OH-GUA) mean scores were statistically lower in the control group in comparison with the cisplatin group (-55.48%, -67.99%, and -48.81% PC, respectively; P < 0.01). Finally, tGSH and NO end product levels were restored to normal (85.90% and 55.30% PC, respectively), and MDA, MPO, and 8-OH-GUA were significantly reduced by treatment with mirtazapine (-60.50%, -78.59%, and -38.10% PC, respectively; P < 0.01).

CONCLUSION

Mirtazapine has chemoprotective effects against cisplatin-induced oxidative stress and DNA damage in the rat brain, which may be attributed to its antioxidant capabilities. It would be useful to investigate whether cisplatin at the desired doses can be given concurrently with mirtazapine.

The occurrence of priapism as a result of the use of a single dose of quetiapine

Priapism is a prolonged pathologic erection situation that occurs after sexual stimulation or without sexual stimulation. This condition is divided into two types, ischemic (low-flow, veno-occlusive) and non-ischemic (high-flow, arterial). A 68-year-old male patient applied to our clinic with the complaints of hardness and pain in the penis. Three days before he applied to our clinic, he was prescribed a single dose of 200 mg quetiapine by a psychiatry polyclinic for the complication of insomnia. Nearly 6 hours after the first dose of quetiapine, an involuntary erection occurred with accompanying pain in the penis. The patient waited for spontaneous detumescence without consulting a psychiatrist. After the patient had waited for 48 hours without any change, he applied to our clinic. Other etiologic factors of priapism were excluded (such as malignancy, blood dyscrasia, leukemia, and trauma). In blood gas samples obtained from the corpus cavernosum, hypoxia, hypercarbia, and acidosis were diagnosed. Ischemic priapism was supposed. We conclude that priapism can be viewed as a new possible side effect of quetiapine and that patients should be warned about this side effect.

Ketofol (Mixture of Ketamine and Propofol) Administration in Electroconvulsive Therapy

The aim of this study was to evaluate the effect of a ketamine:propofol combination (‘ketofol’) for electroconvulsive therapy on seizure activity, haemodynamic response and recovery parameters, and to compare with these with the effects of propofol alone. Twenty-four patients underwent a total of 144 electro-convulsive therapy sessions, allocated in this prospective, double-blind, crossover study. Patients were randomly assigned to receive 1 mg/kg ketofol (0.5 mg/kg propofol plus 0.5 mg/kg ketamine) or 1 mg/kg propofol 1% for anaesthesia induction. Seizure duration and quality, haemodynamic data, recovery parameters and side-effects were recorded and analysed between groups. Both motor and electroencephalography seizure durations in the ketofol group (29±17 and 41±17 seconds, respectively) were similar to that in the propofol group (28±13 and 38±16 seconds, respectively). Postictal suppression index was higher in the ketofol group (89.63±7.88) than in the propofol group (79.74±14.6) (P P <0.05). There were no untoward psychological reactions following ketofol. Although no superiority to propofol in terms of seizure duration, haemodynamic or recovery parameters was found, the ketofol mixture selected in our study provided better seizure quality than propofol. We conclude that ketofol can be an alternative strategy to enhance the seizure quality and clinical efficiency of electroconvulsive therapy.

Single intrathecal fentanyl for combined spinal epidural anesthesia confers no advantage over hemodynamic effects in elderly patients

BACKGROUND

Neuroaxial blockade for ambulatory transurethral resection of the prostate is a well established technique. Patients in this group are often at high risk for perioperative complications from concurrent diseases. The purpose of this study was to compare the elderly patients who received intrathecal fentanyl alone or intrathecal fentanyl plus bupivacaine or epidural anesthesia for transurethral resection of prostate surgery.

MATERIAL AND METHODS

Ninety-nine patients were prospectively randomized to receive fentanyl 25 microg (Group F), fentanyl 25 microg plus hyperbaric bupivacaine 2.5 mg (Group BF), or epidural anesthesia adding fentanyl 50 microg (Group E) by combined spinal epidural anesthesia technique.

RESULTS

The amount of local anesthetics used until when the sensorial block reached the level of T10 was significantly lower in the Group BF than in the Group E and the Group F (p < 0.001). Maximum level of sensory block was significantly lower in the Group BF than in the Group E and the Group F (p = 0.01). The time elapsed until the sensory block reached T10, the regression of sensory block to L5 level were significantly lower in the Group BF than in the Group E and the Group F (p = 0.005, p < 0.001, respectively). Compared to the basal values, mean arterial pressures were significantly lower in the Group BF than in the Group E and the Group F (p < 0.05). The occurrence of hypotension was significantly lower in the Group BF (9.4%) than in the Group E (18.2%) and the Group F (24.2%).

CONCLUSIONS

Intrathecal hyperbaric bupivacaine 2.5 mg plus fentanyl 25 microg administration provides shorter motor block onset time, less local anesthetic usage and adequate hemodynamic stability in elderly patients.

The effect of venlafaxine on ongoing and experimentally induced pain in neuropathic pain patients: a double blind, placebo controlled study

BACKGROUND AND AIM

The aim of this randomized double blind placebo controlled study was to investigate the effectiveness and the safety of venlafaxine XR 75 and 150 mg on ongoing pain and on quantitative sensory tests in 60 patients with neuropathic pain for 8 weeks.

METHODS

Evaluation parameters consisted of ongoing pain intensity (VAS), patient satisfaction, side effects, global efficacy and tolerance. Quantitative sensory measurements taken from the affected area before and after the drug treatment included pin-prick hyperalgesia, allodynia, detection and pain thresholds to electrical and heat stimuli, temporal summation of repetitive electrical and heat stimuli.

RESULTS

A total of 55 patients completed the study. VAS scores decreased significantly compared to the baseline measurements in all groups. There was no significant difference between the groups regarding pain intensity and escape medication. The areas of allodynia and pin-prick hyperalgesia decreased significantly in venlafaxine groups compared to the placebo. There was no significant difference between the groups regarding the detection thresholds (electrical and heat). The pain threshold and the summation threshold to electrical stimuli and the summation threshold to heat stimuli increased significantly following treatment in both venlafaxine groups. In addition, the degree of the temporal summation to electrical and heat stimuli decreased significantly following treatment in both venlafaxine groups compared to the placebo.

CONCLUSION

The study showed significant effect of venlafaxine in the manifestations of hyperalgesia and temporal summation, but not on the ongoing pain intensity. Furthermore, the quantitative sensory tests provided complementing information to the clinical measures.

Volumetric evaluation of hemicerebellar changes in migraine patients without aura

Brain balance changes have been recognised in migraine, but cerebellar function between or during attacks has been assessed only in a few studies. Previous studies have indicated that migraine affects cerebellar function. In the present study we aimed to evaluate the hemicerebellar volume changes of patients with migraine without aura (MWoA). Volumetric changes of cerebellar hemispheres were evaluated in terms of asymmetry using stereological methods on magnetic resonance images (MRI) retrospectively. Nineteen patients with MWoA and 18 age- and gender-matched control subjects were included in the study. MRIs were analysed by using the point-counting approach of stereological methods by Cavalier's principle. There was no statistically significant cerebellar atrophy or hemicerebellar asymmetry between the MWoA and control subjects. There was no cerebellar atrophy or asymmetry between the MWoA and age-matched control group. The stereological evaluation of cerebellar asymmetry and atrophy in humans is important for both clinicians and anatomists. The technique is simple, inexpensive, and reliable.

The role of human herpesvirus 6, human herpesvirus 7, Epstein-Barr virus and cytomegalovirus in the aetiology of pityriasis rosea

AIM

To identify the role of human herpesvirus 6 (HHV-6), HHV-7, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) in the pathogenesis of pityriasis rosea (PR).

MATERIAL

Polymerase chain reaction with specific primers for HHV-6 and HHV-7 DNA sequences was performed on the blood and tissue samples of 25 patients with PR and on the blood samples of age- and sex-matched healthy controls. HHV-6, EBV, CMV immunoglobulin M (IgM) and IgG were analysed by enzyme-linked immunosorbent assay, HHV-7 IgM and IgG were analysed by indirect immunofluorescence on the serum samples of the study population. In the patient group, the values were studied 2 weeks later again (second control).

RESULTS

There were no differences between the first and second controls of the patients and healthy subjects regarding HHV-6 IgM, HHV-7 IgM, CMV IgM, EBV IgM results. There were significant differences between the first [HHV-6 DNA (2 of 25), HHV-7 DNA (6 of 25)] and second control [HHV-6 DNA (1 of 25), HHV-7 DNA (11 of 25)] of the patients for the blood samples in favour of HHV-7. PR patients showed higher amounts of HHV-6 and HHV-7 DNA positivity when compared with that of healthy subjects. HHV-7 seemed to be more important regarding tissue samples [HHV-6 DNA (7 of 25), HHV-7 DNA (12 of 25) first control, HHV-6 DNA (6 of 25), HHV-7 DNA (12 of 25) second control] as well as blood samples.

CONCLUSION

Though our results failed to support a causal relationship among EBV, CMV and PR, they indicated a possible role for HHV-6 and especially HHV-7 in a group of Turkish patients but other aetiological factors may exist.

Sonographically guided fine-needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material

AIM

To evaluate the effects of sonographic characteristics of thyroid nodules, the diameter of needle used for sampling, and sampling technique on obtaining sufficient cytological material (SCM).

MATERIALS AND METHODS

We performed sonography-guided fine-needle biopsy (FNB) in 232 solid thyroid nodules. Size-, echogenicity, vascularity, and localization of all nodules were evaluated by Doppler sonography before the biopsy. Needles of size 20, 22, and 24 G were used for biopsy. The biopsy specimen was acquired using two different methods after localisation. In first method, the needle tip was advanced into the nodule in various positions using a to-and-fro motion whilst in the nodule, along with concurrent aspiration. In the second method, the needle was advanced vigorously using a to-and-fro motion within the nodule whilst being rotated on its axis (capillary-action technique).

RESULTS

The mean nodule size was 2.1+/-1.3 cm (range 0.4-7.2 cm). SCM was acquired from 154 (66.4%) nodules by sonography-guided FNB. In 78 (33.6%) nodules, SCM could not be collected. There was no significant difference between nodules with different echogenicity and vascularity for SCM. Regarding the needle size, the lowest rate of SCM was obtained using 20 G needles (56.6%) and the highest rate of adequate material was obtained using 24 G needles (82.5%; p=0.001). The SCM rate was 76.9% with the capillary-action technique versus 49.4% with the aspiration technique (p<0.001).

CONCLUSION

Selecting finer needles (24-25 G) for sonography-guided FNB of thyroid nodules and using the capillary-action technique decreased the rate of inadequate material in cytological examination.

Effect of dexmedetomidine on bleeding during tympanoplasty or septorhinoplasty

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the efficacy of dexmedetomidine, an alpha(2)-adrenoceptor agonist, on intraoperative bleeding, anaesthetic drug requirement and postoperative pain.

METHODS

Forty patients scheduled for elective tympanoplasty and septorhinoplasty operations under general anaesthesia were included in the study. The patients were randomly assigned to receive either a dexmedetomidine 1 microg kg(-1) bolus 10 min before induction of anaesthesia plus 0.5 microg kg(-1) h(-1) infusions during maintenance or placebo. Mean arterial pressure was maintained between 60 and 80 mmHg. Perioperative mean arterial pressure, heart rate, time to extubation and time to awakening were recorded. Bleeding during surgery was assessed by the surgeon, blinded to the study drugs, both intraoperatively and postoperatively as a final personal opinion about the whole surgical process.

RESULTS

The heart rate and mean arterial pressure were significantly lower during induction, operation and extubation in the dexmedetomidine group (P < 0.05). Blood losses were lower in the dexmedetomidine group (P < 0.05). Propofol dose required for induction, and fentanyl and isoflurane consumption were significantly reduced in the dexmedetomidine group (P < 0.05). The total amounts of nitroglycerin and meperidine used were higher in the control group (P < 0.05).

CONCLUSIONS

Dexmedetomidine decreased bleeding, postoperative analgesic requirements and intraoperative anaesthetic requirements and was associated with more stable haemodynamic responses to anaesthesia. We conclude that dexmedetomidine is a useful adjuvant to decrease bleeding when a bloodless surgical field is requested.

The effects of single-dose tramadol on post-operative pain and morphine requirements after coronary artery bypass surgery

AIM

To investigate the effects of a single dose of tramadol administered prior to extubation on post-operative pain and morphine consumption after coronary artery bypass surgery.

METHODS

Patients were randomized post-operatively into two groups (group T, n= 30; group P, n= 30). The technique of anaesthesia was standardized for all patients. The patients in group T received intravenous tramadol, 1 mg/kg, and the patients in group P received 2 ml of saline 0.9%, both approximately 1 h before extubation. After extubation, all patients were allowed to use the morphine patient-controlled analgesia (PCA) device for 24 h post-operatively. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anaesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated.

RESULTS

In group P, the visual analogue scale (VAS) scores were found to be higher 30 min (P < 0.01), 1 h (P < 0.01), 2 h (P < 0.01) and 4 h (P < 0.05) after extubation. The patient comfort scores were higher in group T 30 min (P < 0.01), 1 h (P < 0.05), 2 h (P < 0.01) and 4 h (P < 0.01) after extubation. The total morphine consumption was higher in group P at all evaluation times (P < 0.01), and the numbers of PCA demands and boluses were also higher in group P (P < 0.01).

CONCLUSIONS

The study demonstrated that a single dose of tramadol administered prior to extubation following coronary artery bypass surgery is associated with a decrease of up to 25% in morphine consumption, a decrease in the VAS scores and an improvement in patient comfort within the first 4 h post-operatively.

Vitiligo and ocular findings: a study on possible associations

OBJECTIVE

In this study, we aimed to evaluate the ocular findings in vitiligo patients and reveal any clinical feature that might suggest an association or a risk factor.

BACKGROUND

Very few reports in the literature are available about the ocular findings in vitiligo and the possible associations of the ocular findings in vitiligo patients have not been studied so far.

METHODS

A total of 45 patients with previously documented cutaneous vitiligo were examined for ocular findings. Demographic features including age, gender, duration of vitiligo, presence of associated autoimmune diseases, type of vitiligo and the anatomical distributions of vitiligo were recorded to evaluate a possible relationship with the ocular findings. Univariate and multivariate analyses as well as cluster analysis were performed. After description of the clusters, the Mann-Whitney U-test and Fisher's exact test were used to determine the variables. Concordance among the variables in each group was evaluated with the McNemar test.

RESULTS

Ten patients had ocular findings that included anterior segment (iris) involvement, ring-like peripapillary atrophy around the optic nerve, atrophy of pigment epithelium, focal hypopigmented spots and diffuse hypopigmentation. The presence of periorbital vitiligo was significantly related to the ocular findings. Cluster analysis revealed concordances between periorbital and genitalial localizations of vitiligo and ocular findings.

CONCLUSION

The number of patients and the range of ocular findings in our study are insufficient to make definite conclusions but anatomical localizations, primarily periorbital and to a lesser extent genitalial vitiligo, seem to be the most probably alerting features for ocular findings.

Control of shivering during regional anaesthesia: prophylactic ketamine and granisetron

BACKGROUND

The aim of the present study was to compare placebo, ketamine, granisetron and a combination of ketamine and granisetron in the prevention of shivering caused by regional anaesthesia.

METHODS

In this prospective, randomized, double-blind study, 160 ASA I and II patients undergoing urological surgery were included. Subarachnoid anaesthesia was performed in all patients with bupivacaine 15 mg. The patients were randomly allocated to receive saline (group P, n= 40), ketamine 0.5 mg (group K, n= 40), granisetron 3 mg (group G, n= 40) or ketamine 0.25 mg + granisetron 1.5 mg (group KG, n= 40). Shivering was graded as 0 = no shivering, 1 = piloerection or peripheral vasoconstriction but no visible shivering, 2 = muscular activity in only one muscle group, 3 = muscular activity in more than one muscle group but not generalized, and 4 = shivering involving the whole body. If 15 min after spinal anaesthesia and concomitant administration of a prophylactic dose of one of the study drugs, the patients shivered according to at least grade 3, the prophylaxis was regarded as ineffective and intravenous (i.v.) pethidine 25 mg was administered.

RESULTS

After 15 min, the number of patients with observed shivering was 22 in group P, 6 in group G, 7 in group GK and 0 in group K. The difference between group K and all the other groups was statistically significant (P < 0.0001). The number of patients with a shivering score of 3 was statistically significantly higher in group P compared with the other groups.

CONCLUSION

The prophylactic use of 0.5 mg/kg i.v. ketamine was effective in preventing shivering developed during regional anaesthesia.

Combined sphenoid and frontal sinus aplasia accompanied by bilateral maxillary and ethmoid sinus hypoplasia

We describe CT scans of a case with bilateral aplasia of frontal and sphenoid sinuses with symmetrical hypoplasia of the ethmoid cellules and maxillary sinuses. This case appears to be first in the English-language literature with these combined findings.

Effect of informed consent for intravascular contrast material on the level of anxiety: how much information should be given?

PURPOSE

To compare the effect of two different informed consent forms on patients' anxiety level prior to intravenous contrast material (IVCM) injection.

MATERIAL AND METHODS

Two different informed consent forms were randomly given to 265 consecutive patients referred for either intravenous pyelography or computed tomography requiring IVCM injections. Form 1 had brief information, including only the common risks and risk factors associated with IVCM, while Form 2 had more comprehensive information. Before being presented with the two different informed consent forms, 191 of the 265 patients filled out two other forms evaluating: 1: How they felt in that particular situation/moment (STAI-T); and 2: How they felt independently of the situation or condition at that moment (STAI-S). After the patients were informed, the STAI-T (measuring how they felt in that particular situation) was filled out once more to see if the anxiety level had changed.

RESULTS

The anxiety level for 88 patients receiving Form 1 decreased after they were given the informed consent (P=0.033). However, among the 103 patients receiving Form 2, the anxiety level showed a significant increase (P=0.001) compared to the values obtained before Form 2 was given.

CONCLUSION

These results indicate that informed consent, including brief information about the risk factors and potential adverse reactions of IVCM, reduces anxiety level, while detailed information before the procedure increases the anxiety level.

Effect of pre-emptive ketamine on sensory changes and postoperative pain after thoracotomy: comparison of epidural and intramuscular routes

BACKGROUND

In this study we have evaluated the efficacy of ketamine via i.m. and epidural routes for the control of post-thoracotomy pain.

METHODS

The study was randomized, double blinded and placebo controlled. With the approval of the Faculty Ethics Committee, 60 patients undergoing elective thoracotomy were randomized into three equal groups. Group IM had i.m. ketamine 1 mg kg(-1) in 2 ml plus epidural normal saline; Group EPI had epidural ketamine 1 mg kg(-1) in 10 ml plus i.m. normal saline; Group C had epidural normal saline 10 ml plus i.m. normal saline 10 ml. Anaesthesia was standardized. Postoperative analgesia was maintained with epidural patient-controlled analgesia using bupivacaine and morphine. Visual analogue scale values and analgesic consumption were evaluated at 2, 4, 6, 8, 10, 12, 24 and 48 h after surgery. The areas of allodynia, pin-prick hyperalgesia and pressure hyperalgesia were measured at 48 h, and days 15 and 30 in all groups.

RESULTS

Intraoperative fentanyl requirement was significantly lower in Group EPI than Group C. The morphine and bupivacaine requirements were significantly lower in Group EPI than the other two groups in the postoperative period. There was reduced pin-prick hyperalgesia and touch allodynia in the EPI group. There were no side-effects attributable to ketamine.

CONCLUSION

The results of the present study demonstrate that pre-emptive epidural ketamine is effective in reducing intra- and postoperative analgesic requirements, hyperalgesia and touch allodynia.

Serum hepatocyte growth factor and interleukin-6 levels can distinguish patients with primary or metastatic liver tumors from those with benign liver lesions

Hepatocyte growth factor (HGF) is a potent stimulator of angiogenesis and cancer metastasis. Interleukin-6 (IL-6) is a pleiotropic cytokine that can act as an autocrine or paracrine growth factor in various tumor cells. In this study, we investigated the role of serum HGF and IL-6 levels to distinguish primary or metastatic liver tumors from benign liver lesions. Serum HGF and IL-6 levels were measured in 64 cancer patients and 12 healthy controls. Patients were divided into 5 groups: Group-1 (n=24): Breast cancer patients in complete remission without any liver lesion, Group-2 (n=8): Breast cancer patients in complete remission with benign liver lesion, Group-3 (n=10): Breast cancer patients with liver metastasis, Group-4 (n=11): Metastatic breast cancer patients without liver metastasis, Group-5 (n=11): Patients with hepatocellular carcinoma. Group-6 (n=12): Healthy controls. Serum HGF levels were found to be higher in group-5 (606.4+/-255.8 pg/ml) than those in group-1 (*305.6+/-42.3 pg/ml), group-2 (*293.9+/-44.8 pg/ml), group-4 (**358.4+/-81.9 pg/ml) and group-6 (*305.8+/-24.9 pg/ml) (*p<0.001, **p<0.05). Patients in group-3 (448.9+/-157.3 pg/ml) had higher serum HGF levels than those in group-1, group-2 and group-6 (p<0.05). Serum IL-6 levels were found to be higher in group-5 (54.9+/-37.4 pg/ml) than those in group-1 (9.7+/-6.4 pg/ml), group-2 (9.5+/-4.8 pg/ml), group-4 (17.6+/-19.6 pg/ml) and group-6 (12.6+/-5.2 pg/ml, p<0.05). Patients in group-3 (32.5+/-36.9 pg/ml) had higher serum IL-6 levels than those in group-1, 2 and group-6, but these were not statistically significant (p>0.05). This study showed that primer and metastatic liver tumors had higher serum HGF and IL-6 levels than other patients and controls. Measurements of these markers in serum may be used to distinguish patients with primer liver tumors or breast cancer patients with liver metastasis from those with benign liver lesions or non-metastatic patients.

In-vitro activities of terbinafine, itraconazole and amphotericin B against Aspergillus and Cladosporium species

The in vitro fungicidal and fungistatic activities of terbinafine were compared with those of itraconazole and amphotericin B against Aspergillus (n=63) and Cladosporium (n=21) isolates. The broth macrodilution modification of NCCLS reference method for filamentous fungi (M38-P) was used to assess the minimum inhibitory concentrations (MICs). Our data show that the in vitro activities of terbinafine were comparable to those of itraconazole and amphotericin B against the Aspergillus spp and Cladosporium strains tested. Despite strain-dependent variabilities, in general, itraconazole's activity was similar to that of amphotericin B against strains of Aspergillus and Cladosporium. Our data suggest that terbinafine may be useful in the treatment of Aspergillus and Cladosporium infections.

The effect of heat conditioning of the primary area before and after induction of hyperalgesia by topical/intradermal capsaicin or by controlled heat injury

The aim of the present study was to test the effect of heat conditioning before and after the induction of hyperalgesia. Three different methods were used for induction of hyperalgesia, topical capsaicin, intradermal capsaicin injection, and a controlled heat injury. The vascular (blood flow and skin temperature) and sensory changes (area of secondary hyperalgesia and ongoing pain) associated with the cutaneous hyperalgesia were compared. Each experiment consisted of two randomized sessions separated by at least 2 days. In one session, pre-conditioning of the skin by heat was performed 30 min before the induction of hyperalgesia using a probe at 45 degrees C for 5 min in the center of the expected primary hyperalgesic area. After the induction of hyperalgesia, heat conditioning was performed twice in the center of the primary hyperalgesic area using a temperature of 2 degrees C above the present individual pain threshold. On the contra-lateral arm, no heat conditioning was applied while hyperalgesia was induced using the same method. This session was evaluated as a control. The pre-conditioning induced an increased skin temperature in the primary area for both topical capsaicin and the controlled heat injury. Post-conditioning caused increased blood flow in the secondary hyperalgesic area for the topical capsaicin method and increased blood flow in the primary hyperalgesic area for the controlled heat injury method. However, conditioning with heat in an attempt to increase the C-fiber input did not have any effect on the ongoing pain ratings and sensory test results in any of the methods. The results of the present study suggest that there is still a need for a better experimental model with more stable allodynia both between sessions and between subjects while at the same time minimizing discomfort to the volunteer.

Feto-maternal morbidity and mortality after cardiac valve replacement

BACKGROUND

The aim of this study is to evaluate the fetomaternal morbidity and mortality of the pregnancies of women who conceived after cardiac valve replacement.

METHODS

A consecutive series of one hundred and thirty-six pregnancies of one hundred and one patients who conceived after cardiac valve replacement were retrospectively analyzed. Regarding the anticoagulation therapy, 101 patients were classified into three groups: A: patients on oral anticoagulants (n=68), B: patients on heparin (n=16) and C: patients who received no anticoagulation (n=17).

RESULTS

Three groups (patients on oral anticoagulants (A), on heparin (B), patients who received no anticoagulation (C)) were compared in terms of spontaneous abortion (19%, 11%, 5.6%), preterm delivery (14%, 22.3%, 16.6%), maternal mortality (3%, 11.1%, 0%), thromboembolic events (4%, 11.1%, 0%), cardiac failure (6%, 11.1%, 11.1%), atrial fibrillation (9%, 11.1%, 5.6%), antenatal bleeding (9%, 11.1%, 5.6%), delivery route and fetal malformation (5%, 0%, 0%) and no statistically significant differences were detected. In group B, hematoma formation rate (22.2%) (p=0.011) and transfusion rate (27.8%) (p=0.005) were significantly higher. Five cases of congenital anomalies were detected, all belonging to group A, but this tendency was not found to be statistically significant.

CONCLUSIONS

Management of pregnancies with prosthetic heart valves require closely monitored anticoagulation, and an obstetrician should be familiar with the potential fetal and maternal adverse effects of any anticoagulant therapy during the course of pregnancy.