Efficacy of telemedicine applications in patients with diabetic foot ulcers: A focus on mortality and major amputation rates

Amputations related to diabetic foot ulcers (DFU) are associated with high morbidity and mortality rates. Glycaemic control and close follow-up protocols are essential to prevent such ulcers. Coronavirus disease (COVID) related restrictions and regulations might have a negative impact on patients who are with DFU or candidates for DFU. We retrospectively analysed 126 cases that had DFU underwent amputation surgery. Comparative analyses were done between cases that were admitted before COVID restrictions (Group A) and cases admitted after COVID restrictions (Group B). Two groups were homogenic demographically. There was no significant difference between groups in terms of mortality (p = 0.239) and amputation rates (p = 0.461). The number of emergent cases in the pandemic period doubled the number in pre-pandemic period even though this finding was not statistically significant (p = 0.112). Fastly adapted consulting practice and follow-up protocols to compensate for the problems created by COVID-related regulations seem to be effective in terms of mortality and amputation rates.

The mediating role of FoMO and the moderating role of narcissism in the impact of social exclusion on compulsive buying: a cross-cultural study

BACKGROUND

There is an interrelationship between the concepts of social exclusion, compulsive buying behavior, fear of missing out (FoMO), and narcissism. Nevertheless, the extent to which these concepts mediate or moderate their relationships with each other has not been efficiently investigated.

OBJECTIVE

This research aims to investigate how FoMO mediates and narcissism moderates the correlation between social exclusion and compulsive buying behavior. In addition, the research aims to test a conceptual model and highlight the differences that may occur in the conceptual model proposed in two different countries.

METHODS

This model was analyzed among 1007 university students (Turkey = 506, Denmark = 501). The study used scales to measure social exclusion, compulsive buying behavior, FoMO, and narcissism. The study employed PROCESS Model 4 to analyze direct and indirect (mediation) effects and PROCESS Model 59 to assess conditional (moderation) effects. Furthermore, the Johnson-Neyman technique was utilized to investigate interaction terms.

RESULTS

The findings indicate that those who face social exclusion tend to participate more in compulsive buying, and this connection is partly explained by FoMO. This suggests that individuals who encounter social exclusion may have an increased likelihood of experiencing FoMO, which may subsequently contribute to compulsive buying behavior. Furthermore, the moderating effect of narcissism differed between the Turkey and Danish samples. Specifically, in the Turkey sample, narcissism only modified the connection between social exclusion and FoMO, while in the Danish sample, it impacted both the connection between social exclusion and FoMO and the connection between FoMO and compulsive buying.

CONCLUSION

The obtained results show that the regulating role of narcissism is different in Turkey and Denmark within the conceptual model we studied.

Ertapenem plus meropenem combination treatment in carbapenem-resistant Klebsiella pneumoniae bacteremia: an analysis of 53 cases

Herein, we aimed to describe the outcomes of patients with blood stream infections due to carbapenem-resistant Klebsiella pneumoniae (CR-Kp) who received ertapenem plus meropenem combination treatment (EMCT). A total of 53 patients with culture proven CR-Kp bacteremia treated with ertapenem + meropenem were included. The patients with secondary bacteremia due to urinary tract infection exhibited a significantly lower 1-month mortality (OMM), particularly in those with microbiological eradication and those with end-of-treatment success. Salvage EMCT resulted in 49% 1-month survival.

Safe Use of Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot Ulcers: A Multidisciplinary Approach to Minimize Adverse Effects

Purpose

The purpose of this study is to evaluate the side effects associated with hyperbaric oxygen therapy and provide recommendations to prevent them in patients with diabetic foot ulcers.

Introduction

The use of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers remains a contentious issue, and minimizing side effects is critical. While the incidence of side effects related to hyperbaric oxygen (HBO2) therapy is low, it is essential to evaluate cases in a multifaceted and interdisciplinary manner to prevent adverse outcomes.

Methods

A retrospective cohort study was conducted over the period of 2018-2020, involving a dataset of 100 patients. The primary objective of the study was to examine the frequency and types of side effects experienced by patients who underwent hyperbaric oxygen therapy (HBO) for diabetic foot ulcers (DFUs). In addition, we analyzed various wound characteristics, characteristics of hospitalizations, the surgical or medical interventions received by patients, and laboratory parameters including CRP levels, total blood count, culture results, HbA1c levels, duration of diabetes, treatment received for diabetes, and antibiotic therapy regimens.

Results

The percentage of patients who experienced side effects was as low as 6%, and none of them were critical. The most common side effect was discomfort due to the confined space in the chamber.

Conclusion

Appropriate patient selection, combined with a multidisciplinary approach to evaluate eligibility, is crucial to avoid adverse side effects. Patient education and early screening for side effects are also essential. Since various treatment protocols exist for HBO2 therapy, pooled data from different protocols may be misleading. Further studies focused on side effects with specific indications are necessary.

THE RELATIONSHIP BETWEEN TSH LEVELS, THYROID AUTOANTIBODIES AND ATHEROGENIC INDEX OF PLASMA, AST TO PLATELET RATIO INDEX SCORE, AND FIBROSIS 4 INDEX IN PATIENTS WITH HYPOTHYROIDISM

Context

Thyroid hormones have metabolic effects such as relationship between hypothyroidism and atherosclerosis.

Objective

Evaluate the effects of hypothyroidism on Non-Alcoholic Fatty Liver Disease and atherosclerosis by using AIP, APRI score, FIB-4 indices.

Material and Methods

1370 patients with hypothyroidism who applied to the Endocrinology and Metabolism outpatient clinic between 01.01.2017-30.12.2021 were included the study. Pregnants, patients with a history of thyroid carcinoma, cardiovascular and liver diseases were excluded. TSH, fT4, Anti TPO, Anti TG, thrombocyte, ALT, AST, HDL, Triglyceride values of the cases were analyzed and atherogenic index of plasma (AIP), AST to Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) indices were calculated.

Results

1170 (85.4%) of the cases were female.The age of those who had high risk of AIP was found to be higher than those with low and moderate risk (p=0.001; p=0.003; p<0.01). The ages of those who had low-risk FIB-4 Index were found to be lower than those with moderate risk and high risk (p=0.001; p=0.001; p<0.01). A positive relationship was detected between APRI and FIB-4 (r=0.681; p=0.001; p<0.01).AIP increased as TSH increased in hypothyroid patients. No significant correlations were detected between TSH, APRI, and the FIB-4 Index. No significant differences were detected between AIP, APRI, FIB-4, and thyroid autoantibodies.

Conclusion

In hypothyroid patients, the AIP index increased with age and the increase in TSH. A strong relationship was detected between AIP and TSH . For this reason, we think that keeping TSH within the normal range with regular follow-ups and treatment in patients with hypothyroidism will reduce the risk of atherosclerosis.

Carbapenem-resistant Gram-negative pathogens associated with septic shock: a review of 120 cases

This study aimed to evaluate the influencing variables for outcomes in patients with septic shock having culture-proven carbapenem-resistant Gram-negative pathogens. It included 120 patients (mean age 64.29 ± 1.35 years and 58.3% female). The mean Sequential Organ Failure Assessment score during septic shock diagnosis was found to be 11.22 ± 0.43 and 9 ± 0.79 among the patients with mortality and among the survivors, respectively (P = 0.017). The logistic regression analysis showed that empirical treatment as mono Gram-negative bacteria-oriented antibiotic therapy (P = 0.016, odds ratio (OR) = 17.730, 95% confidence interval (CI): 1.728-182.691), Charlson Comorbidity Index >2 (P = 0.032, OR = 7.312, 95% CI: 5.7-18.3), and systemic inflammatory response syndrome score 3 or 4 during septic shock diagnosis (P = 0.014, OR = 5.675, 95% CI: 1.424-22.619) were found as independent risk factors for day 30 mortality. Despite early diagnosis and effective management of patients with septic shock, the mortality rates are quite high in CRGNP-infected patients.

219. Is the modified quick SOFA scale superior to quick SOFA in patients with diagnosed septic shock?

Background

In this study it was aimed to compare the effects of qSOFA (Quick Sequential Organ Failure Assessment) score with modified qSOFA score (PLoS One. 2018 Sep 26;13(9):e0204608) for predicting one month survival in patients with diagnosed septic shock (SS) in a tertiary-care educational university hospital in a developing country.

Methods

Modified qSOFA was created by adding age factor (>50 years=1 point) to patients with qSOFA scale 1 or 2 or 3 who had SS (sepsis+hypotension+adrenergic agent) and consulted by Infectious Diseases consultants between December 2013-December 2018. Arterial lactate level of >2 mmol/L criterion was added as an including criteria for SS according to 3^rd International Sepsis and Septic Shock Consensus Statement after 23^rd February 2016. Statistical analysis was performed via Chi-square test and a p-value <0.05 was considered significant.

Results

The number of patients with qSOFA score of 1 or 2 or 3 from 527 patients are in Table1 [some of the cases were diagnosed as septic shock according to elder definition (without lactate criterion) and there was a subgroup with qSOFA score 1]. Among the >50-year aged group, the 30-day survival rate was lower in patients with qSOFA3 vs. qSOFA 2 vs. qSOFA 1 (Table1, 3x2 Chi Square test, P = 0.0057). Among the <50 years group, the qSOFA one month survival rate was lower in patients with qSOFA 3 vs. qSOFA 2 vs. qSOFA 1 (Table, 3x2 Chi Square Test, P = 0.0052). According to modified qSOFA, there was a significant difference for one month survival among SS cases with scores of 1, 2, 3 and 4 (12/21 57% vs. Fifty/126 40% vs. 78/269 29% vs. 22/111 20%, 4x2 Chi-square test, P = 0.0003). On the other hand, there was no significant difference in terms of one month survival when we performed subgroup analysis in qSOFA score 1, 2, or 3 subgroups, as ≤50 years vs. >50 years (table, Chi-square test, 12/21 vs. 39/97 P = 0.224, 11/29 vs. 75/244 P = 0.526, 3/25 vs. 22/111 P = 0.572).

Conclusion

In terms of survival at one month, there was a significant difference between qSOFA score 1, 2, 3 and 4 subgroups. In patients with qSOFA score of 1 or 2 or 3, being under 50 years did not have a significant effect on one-month survival. Modified qSOFA may be beneficial to foresee the probable mortality but these findings need to be validated in larger cohorts

Disclosures

All authors: No reported disclosures.

BILATERAL ADRENAL AND TESTICULAR MASS IN A PATIENT WITH CONGENITAL ADRENAL HYPERPLASIA

Introduction

Congenital adrenal hyperplasia (CAH) autosomal recessive disorders characterized by impaired adrenal steroid hormone synthesis. The most common form is 21-hydroxylase deficiency (21OHD). Testicular adrenal rest tumors (TARTs) are benign intratesticular masses that occur in male patients with CAH. TARTs are quite common in patients with 21OHD who were diagnosed late.

Case report

A 41-year-old male patient with CAH secondary to 21OHD. The patient was referred to our endocrinology department from the andrology clinic for bilateral adrenal masses. Bilateral orchiectomy had been performed due to bilateral testicular masses and azoospermia two years ago. The pathology was reported as Leydig cell tumor. In hormonal assessment, baseline cortisol levels were low, 17-hydroxyprogesterone levels with baseline and after cosyntropin stimulation test were high. As a result of clinic and laboratory assessment, the patient was diagnosed with simple virilising CAH due to 21OHD and adrenal insufficiency. Then, prednisolone replacement was initiated. Bilateral orchiectomy tissue blocks of the patient were re-assessed and were considered TART. Magnetic resonance imaging revealed bilateral adrenal masses with 88x55 mm on the right and 41x22 mm on the left. Laparoscopic right adrenalectomy was applied and pathology was reported as myelolipoma. Follow-up of the mass on the left adrenal gland is ongoing. The patient is monitored under prednisolone and testosterone replacement therapy. Early diagnosis of CAH is very important because of the complications it causes. It should be considered especially for bilateral testicular and/or adrenal masses. Both fertility and adrenal glands can be protected with an early diagnosis and an early glucocorticoid replacement.

The Differences Between Preterm and Term Birth Affecting Initiation and Completion of Toilet Training Among Children: A Retrospective Case-Control Study

PURPOSE

This study seeks to investigate the possibility the existence of a difference in terms of start and end dates of toilet training between term and preterm children as well as the possible determining factors.

MATERIALS AND METHODS

This study was conducted as a 5-year retrospective case (children born preterm-(32 to <37 weeks) - and control (children born at term (>37 weeks + 1 day)) study. The data were collected with a form consisted of questions about demographic data (12 questions) and toilet traning features (10 questions) through face-to-face interviews with the mothers. A chi-square test and logistic regression analysis were conducted to examine the data. Odds ratio was used as a measure of the relation between levels of the dependent variable. p< .01 and p< .05 values were assumed to be statistically significant.

RESULTS

The study examined a total of 133 children including 59 preterm children and 74 children born at term including 60 (45.1%) boys and 73 (54.9%) girls. The possibility of starting toilet training at or before 24 months was found to be 6.4 times greater in full-term children than preterm children (OR=6.493). The logistic regression analysis, which aimed at identifying any variables that might affect end date of toilet training, found that despite the tendency to consider preterm   birth as a factor prolonging the duration of toilet training, the difference was not found to be statistically significant (p= .07).

CONCLUSION

This study compared full-term and preterm children in terms of start and end dates of toilet training and found that preterm children start toilet training later than full-term children. Based on the results of the study, it is possible to say that preterm birth, gender and birth order affect start date of toilet training. However there is no difference between term and preterm babies on the end date of toilet training.

Inflammatory cytokines IL-6 and TNF-α in patients with hip fracture

Mortality and remaining bedridden following the hip fracture surgery are not rare. We tried to measure the levels of inflammatory markers tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) following the hip fracture surgery and compare their levels with controls. We aimed to show a relationship between the levels of these markers and post-operative mortality and walking capability.

INTRODUCTION

Osteoporosis is a condition, causing the hip fractures in the elderly. Hip fractures have a high rate of overall mortality up to 30% following the incident. Cytokines such as IL-6 and TNF-α are suggested to play a role in bone resorption and, thus, in the etiology of osteoporosis.

METHODS

Plasma levels of IL-6 and TNF-α were measured pre-operatively and on the first and second days after the surgery in 40 Turkish hip fracture patients. The levels of these cytokines were compared with 40 Turkish age-matched healthy controls. The levels of these cytokines were compared between the deceased and surviving patients, as well as the existence of walking capability following the surgery.

RESULTS

Significantly higher IL-6 levels were shown on the first and second days after the surgery (p = 0.005; p = 0.01, respectively). The overall death rate of our study group within the 2-year follow-up time was found to be 35%. No statistical significance was found in the means of 2-year follow-up mortality between the patients. Presence of walking capability did not differ between the patients, as well.

CONCLUSION

We demonstrated an association between IL-6 levels and hip fracture in our study group following the surgery. We also suggest that TNF-α and IL-6 levels are not related to the occurrence of death and walking capability after the surgery. However, these findings need further functional and clinical confirmation.

The effects of residual hip deformity on coronal alignment of the lower extremity in patients with unilateral slipped capital femoral epiphysis

PURPOSE

The aim of our explorative study was to compare the differences in the coronal alignments of the hip, knee and ankle on the slip side and non-slip sides in patients with slipped capital femoral epiphysis (SCFE).

METHODS

The study group consisted of 28 patients. On the full-length standing radiographs, measurements of articulo-trochanteric distance (ATD), neck-shaft angle (NSA), femoral offset, hip-knee-ankle axis, femur-tibial angle, mechanical axis deviation ratio (MAD-r), anatomical medial proximal femoral angle (aMPFA), mechanical lateral proximal femoral angle (mLPFA), anatomical lateral distal femoral angle (aLDFA), mechanical lateral distal femoral angle (mLDFA), knee joint line congruency angle, mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal tibial angle (mLDTA), ankle joint line orientation angle (AJOA), and leg length discrepancy (LLD) were performed. The data from the slip side were compared with those from the non-slip side.

RESULTS

At skeletal maturity, there were significant differences between the slip side and non-slip side in ATD (p <0.001), NSA (p <0.001), MAD-r (p <0.001), aMPFA (p <0.001), aLDFA (p = 0.03), mLDFA (p = 0.04), mLDTA (p = 0.02), AJOA (p <0.001) and LLD (p<0.001).

CONCLUSION

Residual deformity in the proximal femur after epiphyseal slip and premature epiphysiodesis could cause changes in the coronal alignment of the lower extremity. We can add lower extremity alignment examination to follow-up protocol to rule out secondary problems in patients with SCFE.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Early Results of Valved Bovine Jugular Vein Conduit for Right Ventricular Outflow Tract Reconstruction

Objective

Many congenital cardiac anomalies present with accompanying severe right ventricular outflow tract (RVOT) obstruction or interruption requiring surgical correction. RVOT reconstruction by means of a conduit is often necessary in the majority of these patients in the early years of life and there are several proposed conduits for this purpose.

Methods

Fourteen patients with different congenital cardiac pathologies underwent RVOT reconstruction with the newly developed bovine valved jugular vein conduit (The Contegra conduit). The function of the conduit is observed by echocardiographic examinations at the hospital discharge and at follow-up visits with special attention to the function of the venous valve and to any gradient on the RVOT.

Results

There were two perioperative mortalities. All the surviving patients are followed for a mean period of 8.07 months (range 2 to 33 months). The function of the venous valve was determined, in 4 patients (33.33%) as without regurgitation, in 7 patients (58.3%) as mild regurgitation and in 1 patient (8.33%) as mild-to-moderate regurgitation. The reconstructed RVOT was free of any significant gradient at the hospital discharge (mean 10.83 ±10.18 mmHg) and at the follow-ups (mean 12.916 ±12.33 mmHg). There was not a trend towards an increase in the gradients following discharge.

Conclusion

The early results of the Contegra valved conduit are very satisfactory. This graft can be a good alternative for RVOT reconstruction, particularly in the neonatal and infant patient group. These patients can be managed by homograft replacement of their conduit in later years.

A new strategy in nursing education: From hybrid simulation to clinical practice

BACKGROUND

Various instructional environments are used in nurse education to develop students' psychomotor and communication skills, reduce their anxiety levels, and enhance their satisfaction.

OBJECTIVES

To examine the effect of three different instructional environments on the development of the students' psychomotor and communication skills and their levels of anxiety and satisfaction.

DESIGN

A prospective study design was used.

METHODS

The study sample consisted of 60 nursing students. Before the implementation of the study, the students' cognitive skills and trait anxiety levels were evaluated. The students were divided into five groups and five nursing activities (Leopold's maneuvers, teaching breastfeeding, family planning education, teaching vulvar self-examination and teaching breast self-examination) were specified for each group. They implemented these nursing activities under the supervision of a faculty member in the nursing skills laboratory (NSL), standardized patient laboratory (SPL) and clinical practice environment (CPE) respectively. In each instructional environment, the students' psychomotor and communication skills, state anxiety levels and satisfactions were evaluated.

RESULTS

The median scores for psychomotor skills [NSL=73.1;SPL=81.5;CPE=88.6] and communication skills [NSL=64.9;SPL=71.6;CPE=79.0] were found to increase as the students went on practicing in a more complicated environment (p<0.05). Similarly, it was determined that the students' anxiety levels decreased as they were practicing incrementally [NSL=33.0;SPL=32.0;CPE=31.0]. As the instructional environments were getting more similar to the reality, the students' satisfaction levels were found to become higher.

CONCLUSIONS

Students who deliberately practice in the instructional environments until they are competent develop their psychomotor skills while reducing their anxiety levels, and enhancing their communication skills and satisfaction. For that reason, the development of students' competency areas is thought to be effective for enhancement of patients and health care workers' safety.

Etiology of hypopituitarism in tertiary care institutions in Turkish population: analysis of 773 patients from Pituitary Study Group database

Hypopituitarism in adult life is commonly acquired and the main causes are known as pituitary tumors and/or their treatments. Since there are new insights into the etiology of hypopituitarism and presence of differences in various populations, more studies regarding causes of hypopituitarism are needed to be done in different ethnic groups with sufficient number of patients. Therefore, we performed a multi-center database study in Turkish population investigating the etiology of hypopituitarism in 773 patients in tertiary care institutions. The study was designed and coordinated by the Pituitary Study Group of SEMT (The Society of Endocrinology and Metabolism of Turkey). Nineteen tertiary reference centers (14 university hospitals and 5 training hospitals) from the different regions of Turkey participated in the study. It is a cross-sectional database study, and the data were recorded for 18 months. We mainly classified the causes of hypopituitarism as pituitary tumors (due to direct effects of the pituitary tumors and/or their treatments), extra-pituitary tumors and non-tumoral causes. Mean age of 773 patients (49.8 % male, 50.2 % female) was 43.9 ± 16.1 years (range 16-84 years). The most common etiology of pituitary dysfunction was due to non-tumoral causes (49.2 %) among all patients. However, when we analyze the causes according to gender, the most common etiology in males was pituitary tumors, but the most common etiology in females was non-tumoral causes. According to the subgroup analysis of the causes of hypopituitarism in all patients, the most common four causes of hypopituitarism which have frequencies over 10 % were as follows: non-secretory pituitary adenomas, Sheehan's syndrome, lactotroph adenomas and idiopathic. With regard to the type of hormonal deficiencies; FSH/LH deficiency was the most common hormonal deficit (84.9 % of the patients). In 33.8 % of the patients, 4 anterior pituitary hormone deficiencies (FSH/LH, ACTH, TSH, and GH) were present. Among all patients, the most frequent cause of hypopituitarism was non-secretory pituitary adenomas. However, in female patients, present study clearly demonstrates that Sheehan's syndrome is still one of the most important causes of hypopituitarism in Turkish population. Further, population-based prospective studies need to be done to understand the prevalence and incidence of the causes of hypopituitarism in different countries.

Vacuum assisted closure improves the quality of life in patients with diabetic foot

BACKGROUND

Diabetes Mellitus (DM) is the most common endocrine disease worldwide. One of the most important chronic complications of this disease is the development of diabetic foot. The management of diabetic foot wounds is quite important with respect to public health.

AIMS

To determine the effect of Vacuum Assisted Closure (VAC) therapy on the quality of life in the treatment of diabetic foot ulcers and compare it with standart wound care.

METHODS

Between May 2007 to December 2008, 67 consecutive patients with diabetic foot ulcers were randomly assigned to VAC therapy (Group 1, n : 30) or standart wound care (Group 2, n : 37). The SF-36 questionnaire was administered the day before and in the month following wound healing. Global analyses of the 8 domains and 2 comprehensive indexes of SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS) were performed. Clinical measures included standard antidiabetic treatment, daily wound care including antiseptic bath, debridement, toe removal for gangrene when necessary, and wound care with conventional methods or VAC. Healing time was calculated as the time from hospital admission to the time of re-epithelization.

RESULTS

There were no differences in the mean age, ulcer size and pulse status of the patients in both groups. Healing time in the VAC group was significantly reduced (p < 0.05). All 8 domains of SF-36 and MCS and PCS scores improved remarkably after VAC therapy.

CONCLUSION

Vacuum Assisted Closure therapy was found to be effective in the treatment of chronic diabetic ulcers. The improvement of quality of life demonstrates a clear-cut indication in this particular group of patients.

Isolated tricuspid valve prolapsed: identification using two- and three-dimensional echocardiography and transoesophageal echocardiography

We present a case of isolated prolapse of the tricuspid anterior leaflet in an asymptomatic 34-year-old man who was referred to our hospital for a routine check up. We performed two-and three-dimensional transoesophageal echocardiography (TEE). We found three-dimensional TEE a useful, non-invasive tool that can provide additional information to two-dimensional echocardiography in the assessment of tricuspid valve prolapse.

Cardiogenic shock due to dynamic left ventricular outflow tract obstruction of acute myocardial infarction: an under-diagnosed complication

We report on a patient who developed cardiogenic shock caused by dynamic left ventricular outflow tract (LVOT) obstruction following percutaneous coronary intervention for anteroseptal acute myocardial infarction.

Transsternal repair of Morgagni hernia in a patient with coexistent ventricular septal defect and Down syndrome

BACKGROUND

Morgagni hernia is a rare diaphragmatic hernia occurring secondary to potential anterior medial defects in the diaphragm. The association of the defect with congenital cardiac pathologies and Down syndrome has already been reported. The defect is repaired usually by transabdominal or transthoracic approaches. Transsternal repair of the hernia is preferred in patients undergoing concomitant open heart surgery.

CASE

An eight-month old child with Down syndrome and congenital hypothyroidism underwent concomitant repair of Morgagni hernia and closure of his ventricular septal defect under cardiopulmonary bypass. The hernia was repaired by the sternotomy approach, without opening the hernia content, before the correction of the cardiac pathology.

COMMENT

As Morgagni hernia can accompany some congenital cardiac anomalies, cardiac surgeons should be familiar with the transsternal approach to the defect which is as effective as other surgical approaches.

Right ventricular outflow tract reconstruction for tetralogy of fallot with abnormal coronary artery: experience with 35 patients

BACKGROUND

An abnormal coronary artery crossing the right ventricle outflow tract (RVOT) complicates complete repair of tetralogy of Fallot (TOF). We have evaluated surgical options for RVOT reconstruction for this group of patients.

METHODS

Between 1984 and 2002, 35 TOF patients with abnormality of coronary arteries underwent total correction. Age of these patients ranged from 1 to 14 years (mean 5.8 +/- 2.8 years). All patients were diagnosed by echocardiography and 25 patients had cardiac catheterization. All the abnormal coronary arteries were spared at the operation. In 24 patients a transannular patch was applied for RVOT reconstruction. In three patients with an adequate pulmonary annulus, oblique ventriculotomy incisions, and in two patients, transatrial approaches were performed. "Two-patch" technique was chosen for two patients. In four patients placement of an extracardiac conduit was necessary.

RESULTS

Mortality was observed in four patients, in two of them due to suspected myocardial ischemia. None of the surviving patients needed reoperation. All of them were in NYHA class I. The follow-up period for patients without extracardiac conduit was between 14 and 96 months (mean 50.2 months) and for the patients with extracardiac conduit ranged 36 to 98 months (63.5 months). The mean gradients measured by echocardiography were, respectively, 5 mmHg (range 0 to 35 mmHg) and 23.75 mmHg (range 20 to 25 mmHg).

CONCLUSIONS

Definitive repair of TOF patients with abnormal coronary arteries can be performed in early childhood, but care should be taken to leave at least 1 cm of myocardium between the sutureline and the abnormal coronary artery. Detailed evaluation of the patients preoperatively is mandatory to identify the strategy and timing of the operation.

Early and mid-term angiographic assessment of internal thoracic artery grafts anastomosed to non-stenotic left anterior descending coronary arteries

BACKGROUND

Mild to moderately stenotic coronary arteries present a major problem as the progression of atherosclerosis is unpredictable. In addition, residual flow from the native coronary artery has been proposed as a mechanism that reduces blood flow in bypass grafts resulting in failure of the graft.

PATIENTS AND METHODS

The internal thoracic artery was anastomosed to the left anterior descending coronary artery for different reasons in three patients who underwent coronary arterial surgery, with stenosis of this coronary artery changing from none to 30%. Patients were monitored by coronary arteriography at different intervals postoperatively (from 6 days to 25 months) to assess the patency of the internal thoracic artery graft.

RESULTS

Internal thoracic artery grafts were found to be patent in all coronary arteriographies during the follow-up period. Twenty-five months after surgery, one patient showed total occlusion of the native coronary artery which was previously normal.

CONCLUSIONS

Competitive flow from the native coronary artery does not seem to influence internal thoracic artery patency when grafted to a normal or mildly stenotic left anterior descending coronary artery. This information could be of help in some patients undergoing coronary artery bypass surgery with non-critical stenosis of this coronary artery. If the non-critical lesion is located proximally and if the patient has additional risk factors for coronary artery disease progression, prophylactic grafting of the left anterior descending coronary artery to the internal thoracic artery should be considered to prevent any future cardiac event, keeping in mind that this procedure may accelerate the progression of the native coronary artery disease.

Mid-to-long-term Patency Comparison of the Right Internal Thoracic Artery Grafts on the Left Anterior Descending and on the Right Coronary Arteries

BACKGROUND

The excellent results obtained from internal thoracic artery for myocardial revascularization have led surgeons to simultaneous use of other arterial conduits, particularly the right internal thoracic artery. However, some controversy still exists regarding the optimal target coronary artery for this graft; different strategies have been proposed for bilateral internal thoracic artery grafting.

PATIENTS AND METHODS

59 patients with right internal thoracic artery grafts were monitored using coronary arteriography in order to compare the patency of this graft on the left anterior descending and the right coronary arteries. The right internal thoracic artery was grafted to left anterior descending artery in 39 patients (group 1) and to right coronary artery in 20 patients (group 2).

RESULTS

The mean period of follow-up was 64.07 months (range: 37 to 185 months). Overall, 8 of the 59 grafts (13.6%) were occluded at the arteriography. In group 1, 1 of 39 (2.6%) grafts and in group 2, 7 of 20 (35%) grafts are found to be occluded. These results are considered statistically significant (p < 0.001).

COMMENT

The results show that the patency of the right internal thoracic artery is significantly better on the left anterior descending artery than on the right coronary artery in the mid-to-long term, and patency does not differ from the left internal thoracic artery on the left anterior descending artery.

Radiation-induced coronary artery disease

Radiation-induced heart disease must be considered in any patient with cardiac symptomatology who had prior mediastinal irradiation. Radiation can affect all the structures in the heart, including the pericardium, the myocardium, the valves and the conduction system. In addition to these pathologies, coronary artery disease following mediastinal radiotherapy is the most actual cardiac pathology as it may cause cardiac emergencies requiring interventional cardiological or surgical interventions. Case A 36-year-old man was admitted to the clinic with unstable angina pectoris of one month duration. The patient had no coronary artery disease risk factor. The history of the patient revealed that he had mediastinal radiotherapy due to Hodgkin's disease at 10-year of age. Coronary arteriography showed total occlusion of the left anterior descending artery and 70% stenosis of the proximal right coronary artery. Both arteries are dilated with placement of two stents. Control coronary arteriography at the end of the first year showed patency of both stents and the patient is free of symptoms. Previous radiotherapy to the mediastinum should be considered as a risk factor for the development of premature coronary artery disease. Percutaneous transluminal coronary angioplasty with stent placement or surgical revascularization are the preferred methods of treatment. Preoperative assessment of internal thoracic arteries should be considered prior to surgery. As the radiation therapy is currently the standard treatment for a number of mediastinal malignancies, routine screening of these patients and optimal cardiac prevention during radiotherapy are the only ways to minimize the incidence of radiation-induced heart disease.

Could L-carnitine be an acute energy inducer in catabolic conditions?

Serum free carnitine levels in five children (aged between 2.5 months and 4 years) with the findings of septic shock without disseminated intravascular coagulopathy and seven children (aged between 1.5 and 6.5 years) with the first attack of idiopathic status epilepticus were compared with those of eight healthy children (aged between 2.5 months and 5 years). Serum free carnitine levels showed a statistically significant decrease in the sepsis (mean 51.5 +/- 19 mg/L) and status epilepticus groups (mean 4.1 +/- 12.4 mg/L) (P = 0.006 and P = 0.001, respectively) when compared with the controls (mean 90.8 +/- 17.2 mg/L).