Defining the relationship between ovarian adult granulosa cell tumors and synchronous endometrial pathology: Does ovarian tumor size correlate with endometrial cancer?

OBJECTIVE

The main feature of adult granulosa cell tumors (AGCT) is their capacity to secrete hormones, with nearly all of them capable of synthesizing oestradiol. The primary goal of this study is to identify synchronized endometrial pathologies, particularly endometrial cancer, in AGCT patients who had undergone a hysterectomy.

MATERIALS AND METHODS

The study cohort comprised retrospectively of 316 AGCT patients from 10 tertiary gynecological oncology centers. AGCT surgery consisted of bilateral salpingo-oophorectomy, hysterectomy, peritoneal cytology, omentectomy, and the excision of any suspicious lesion. The median tumor size value was used to define the relationship between tumor size and endometrial cancer. The relationship between each value and endometrial cancer was evaluated.

RESULTS

Endometrial intraepithelial neoplasia, or hyperplasia with complex atypia, was detected in 7.3% of patients, and endometrial cancer in 3.1% of patients. Age, menopausal status, tumor size, International Federation of Gynecology and Obstetrics stage, ascites, and CA-125 level were not statistically significant factors to predict endometrial cancer. There was no endometrial cancer under the age of 40, and 97.8% of women diagnosed with endometrial hyperplasia were over the age of 40. During the menopausal period, the endometrial cancer risk was 4.5%. Developing endometrial cancer increased to 12.1% from 3.2% when the size of the tumor was >150 mm in menopausal patients (p = 0.036).

CONCLUSION

Endometrial hyperplasia, or cancer, occurs in approximately 30% of AGCT patients. Patients diagnosed with AGCT, especially those older than 40 years, should be evaluated for endometrial pathologies. There may be a relationship between tumor size and endometrial cancer, especially in menopausal patients.

Is adjuvant chemotherapy necessary for 2014 FIGO stage IC adult granulosa cell tumor?: Multicentric Turkish study

AIM

The aim of our study is to examine the clinical, surgical, and pathological factors of stage 1C adult granulosa cell tumor (AGCT) patients and to investigate the effects of adjuvant therapy on recurrence and survival rates in this patient group.

METHODS

Out of a total of 415 AGCT patients treated by 10 tertiary oncology centers participating in the study, 63 (15.2%) patients with 2014 FIGO stage IC constituted the study group. The FIGO 2014 system was used for staging. Patient group who received adjuvant chemotherapy was compared with patient group who did not receive adjuvant chemotherapy in terms of disease-free survival (DFS), and disease-specific survival.

RESULTS

The 5-year DFS of the study cohort was 89%, and the 10-year DFS was 85%. Those who received adjuvant chemotherapy and those who did not were similar in terms of clinical, surgical and pathological factors, except for peritoneal cytology. In the univariate analysis, none of the clinical, surgical or pathological factors were significant for DFS. Adjuvant chemotherapy and type of treatment protocol had no impact on DFS.

CONCLUSION

Adjuvant chemotherapy was not associated with improved DFS and overall survival in stage IC AGCT. Multicentric and randomized controlled studies are needed for early stage AGCT in order to confirm these results and reach accurate conclusions.

Comparison of Inguinal Herniotomies with and Without Opening the External Oblique Aponeurosis in Children Above the Age of Two

Background

Mitchell-Banks technique (MBT), in which inguinal canal is not opened, usually used in inguinal hernia repair in children under 2 years of age. The majority of pediatric surgeons tend to open the inguinal canal while performing inguinal hernia surgery in children over 2 years of age, called as modified Ferguson herniotomy (FH).

Aims

This study aimed to compare early and late complications of the MBT and FH in over 2 years of age patients who underwent inguinal hernia surgery.

Patients and Methods

We retrospectively reviewed the medical records of all children between 2 and 16 years old who underwent inguinal herniotomy procedure using the MBT and FH between January 2013 and December 2019. Patients were evaluated in terms of demographic data, early and late complications.

Results

This study included 834 children. Of these, 379 (44.8%) were operated on by an FH with opening the inguinal canal (Group 1), and 455 (55.2%) by MBT superficially to the external ring (Group 2). There were 68 (17.9%) females and 311 (82.1%) males in group 1, while there were 151 (33.2%) females and 304 (66.8%) males in group 2. Early complications were wound infection (1.1% in the group 1 vs. 1.3% in the group 2, P = 1.00) and scrotal hematoma (1.3% vs. 1.8%, P = 0.89). Late complications included recurrence (1.6% in the group 1 vs. 1.8% in the group 2, P = 0.12), undescended testis (2.1% vs. 0.7%, P = 0.71), testicular atrophy (1.5% vs. 0.4%, P = 0.79), and hydrocele (1.9% vs. 1.8%, P = 0.87). There was no statistically significant difference in terms of early and late complications ratio between two groups.

Conclusion

This study showed that inguinal hernia repair performed without opening the inguinal canal in children older than 2 years do not lead to an increase in complications. In this respect, MBT can be used as a simple and safe procedure in older children.

Can we estimate cytokine storm from initial computed tomography images of Coronavirus disease-2019 patients?

OBJECTIVES

The present study aims to investigate whether elementary lesions detected at the time of the diagnosis, their distribution characteristics, and CT scoring can be predictive of a cytokine storm.

BACKGROUND

CT might have a prognostic predictive value beyond its diagnostic value.

METHODS

Sixty-eight patients, 32 with cytokine storm and 36 without cytokine storm, were included in the study. Four different scoring methods were created according to elementary lesions, distribution and involvement rate. CT scores and demographic findings of the cases were compared in the cytokine storm and non-cytokine storm groups.

RESULTS

The mean age of patients was 57.72 (SD: 13.5) and 40 (58.8 %) of them were male. The cytokine storm was significantly more common among male patients and patients of older age (p=0.04).  The AUC values of CT score 1, CT score 2, CT score 3, and CT score 4 were as follows; 0.772 (95% CI; 0.651-0.892), 0.766 (95% CI; 0.647-0.885), 0.758 (95% CI; 0.639-8.78), and 0.760 (95% CI; 0.640-0.881), respectively. All CT scores had better predictive values in males.

CONCLUSIONS

CT scoring at the time of admission can be used to predict cases that may develop cytokine storm later (Tab. 4, Fig. 2, Ref. 15).

One-year outcome of transcatheter repair of tricuspid regurgitation: comparison edge-to-edge repair versus anuloplasty

 

Tricuspid regurgitation (TR) is found to be associated with increased mortality, morbidity, and impaired quality of life. The interventional tricuspid valve repair techniques are being increasingly performed. We aimed to compare the mid-term outcomes of both methods (Clipping and Banding) in our patient cohort. F

We retrospectively included 60 patients who underwent between January 2016 to March 2018 the transcatheter tricuspid valve edge-to-edge repair or annuloplasty in our center. Follow up (FU) examinations were done 12.6±7.6 months. Comprehensive transthoracic echocardiography inclusively 3D acquisitions were performed before and at FU in all patients. The 3D data were used for strain analysis of left and right ventricles and atriums through a dedicated automated offline program (TomTec).

We retrospectively included 60 patients (75±6.1 years, 40% female) with symptomatic (65% ascites, 95% edema, 100% NYHA>II, 75% liver congestion) severe TR (TR>II, 90% functional) at surgical high risk (EuroSCORE II: 5.2±3.2%). Forty patients underwent transcatheter TV edge-to-edge repair (TTVR, MitraClip, PASCAL), and twenty patients were treated by interventional annuloplasty (Cardioband).

At baseline, the patients underwent edge-to-edge (E2E) repair showed more comorbidities with higher EuroScore II and more decreased functional capacity. Echocardiographical, patients who underwent annuloplasty, presented a more significant coaptation gap with more impaired RV function and more dilated right atrium. In contrast, the E2E group showed to have higher right ventricular systolic pressure. Left ventricular dimensions and functions were comparable between the groups.

Left atrial volume and right atrial pressure were found to be statistically significantly reduced in both groups at FU. RV and RA fractional area change were found to be relevantly improved solely after interventional annuloplasty at FU. Left ventricular end-diastolic pressure significantly increased in the E2E group with relevant reduction of outflow/inflow ratio. Moreover, interventional annuloplasty, as expected, reduces SL diameter more significantly.

Patients showed lower symptoms and better functional capacity 12 months after interventional E2E therapy. Of note, improvement in walking distance was found to be significantly higher in patients who underwent annuloplasty. However, patients were hospitalized significantly more frequently after interventional annuloplasty.

In conclusion, both interventional techniques are safe, feasible, and effective for treatment of tricuspid regurgitation in patients at surgical high risk. Interventional annuloplasty significantly impacts on RV function and geometry, and reduces SL diameter significantly. Patients were found to have decreased symptoms, better functional capacity, as well as fewer rehospitalization 12 months after interventional E2E therapy, although they showed more comorbidities at baseline compared to interventional annuloplasty.

Funding Acknowledgement

Type of funding source: None

The prevalence and determinants of complementary medicine use for nigerian children in the Turkish Republic of Northern Cyprus

Background

Complementary and alternative medicine (CAM) is extensively used in the pediatric population. Environments and the nature of diseases have an impact on the type of CAM therapies used in children.

Aims

This study aims to determine the prevalence and determinants of CAM use among Nigerian children living in the Turkish Republic of Northern Cyprus (TRNC).

Subjects and Methods

A quantitative, descriptive and cross-sectional study was conducted among 50 parents living in the TRNC. The parents were selected by the snowball sampling technique. Data were collected using a self-administered, NAFKAM International-CAM-Questionnaire (I-CAM-Q). The data were analyzed using SPSS version 20. Chi-square test was used to analyze the associations of CAM use with values of P < 0.05 considered statistically significant.

Results

The mean ages of the parents and children were 30 ± 5.56 years and 3 ± 2.17 years, respectively. It was discovered that 34 (68%) out of 50 children had used CAM in the previous 12 months. The most commonly used CAM products were vitamins/minerals (82.4%) and herbs/herbal products (55.9%). While praying for health (61.8%) and relaxation techniques (50.0%) were the most used CAM practices. A majority of the parents perceived that CAM use was beneficial (85.3%). Approximately 10% of the children were prescribed CAM recommendation/treatment by physicians. The most used sources of information were relatives (36%) and friends (14.7%). Parents (58%) indicated that they did not disclose their use of CAMs for their children to a physician/nurse.

Conclusions

CAM is used prevalently in this population and the use of CAM is primarily focused on improving well-being. CAM usage for children increases with parental use. Further qualitative research is needed to understand the parental belief in the use of CAMs for children.

Clinical Performance of a Glass Hybrid Restorative in Extended Size Class II Cavities

Objective:

To evaluate the clinical performance of a glass hybrid restorative compared with a resin composite in the restoration of large and deep Class II cavities after 24 months.

Methods and Materials:

A total of 108 extended size, with the width of the proximal box not interfering with the peak of the cusps and the proximal box in occlusion, Class II lesions in 37 patients were either restored with a glass hybrid restorative or with a micro-hybrid composite resin in combination with selective etching by two experienced operators according to the manufacturer's instructions. Two independent examiners evaluated the restorations at baseline and at the six-, 12-, 18-, and 24-month recalls according to the modified US Public Health Service criteria. Negative replicas at each recall were observed under scanning electron microscopy (SEM) to examine surface characteristics. Data were analyzed statistically.

Results:

After 24 months, 90 restorations were evaluated in 32 patients (recall rate: 86.5%). Four glass hybrid restorations were missing; three were due to bulk and one was due to proximal fracture at 12 months. Only six restorations were scored as bravo at baseline and at the six-, 12-, 18-, and 24-month recalls for color (p&lt;0.05). No significant differences were observed between the two restorative materials for the other criteria evaluated (p&gt;0.05). SEM observations exhibited acceptable surface and marginal adaptation characteristics for both restorative materials at 24 months.

Conclusions:

Although glass hybrid restorations showed significant mismatch in color, both restorative materials exhibited successful performance for the restoration of large Class II cavities after 24 months.

42 Comparison of different imaging modalities for the quantification of tricuspid valve geometry and regurgitation

Objectives

Tricuspid regurgitation (TR) is a frequent valvular heart disease with relevant adverse impact on patients´ prognosis. Imaging of tricuspid valve and tricuspid Regurgitation is through anatomical circumstances is challenging. In this study, we aimed to compare the ability of different imaging modalities to visualize and quantify tricuspid valve (TV) function and annular dimensions.

Methods and Results

We prospectively included 40 consecutive patients (Age: 77.5 ± 7.1 years) with high surgical risk (EuroSCORE II: 8.8 ± 12.1%) and significant TR, who underwent transesophageal echocardiography (TEE) and multislice computed tomography (MSCT) to evaluate TR, TV function, and dimensions. In general, 2D-TEE showed lower diameters than MSCT with a significant but weak correlation between both imaging modalities for AP diameters (41.4 ± 7.8 mm, 47.2 ± 8.9 mm, r = 0.68, p = 0.05correlation, p = 0.03difference) and for SL diameters (41.6 ± 5.3 mm, 46.6 ± 4.6 mm, r = 0.71correlation, p = 0.05difference, p = 0.03). We found no significant correlation, however significant difference agreement, between MSCT and 2D-TEE on measures for annulus perimeter (117.6 ± 18.9 mm, 130.3 ± 21.5 mm, r = 0.3, p = 0.4correlation, p = 0.03difference) and annulus area (10.1 ± 3.3 cm2, 13.4 ± 4.1 cm2, r = 0.5, p = 0.4correlation, p = 0.04difference).

When comparing 3D-TEE with MSCT, we found a strong correlation between both imaging modalities concerning TV annulus areas (12.9 ± 2.6 cm2, 13.4 ± 4.1 cm2, r = 0.94, p = 0.0017correlation, p &lt; 0.001difference), and perimeter (130.1 ± 12.4 mm, 130.3 ± 21.5 mm, r = 0.9, p = 0.002correlation, p = 0.005difference), as well as for AP (43.8 ± 3.2 mm, 47.2 ± 8.9 mm, r = 0.73, p = 0.03correlation, p = 0.008difference) and SL diameters (44.5 ± 3.6 mm, 46.6 ± 4.6 mm, r = 0.86, p = 0.02correlation, p = 0.1difference). MSCT was not useful for TR grading and determination of TV function. In addition to conventional 2D echocardiography, only 3D-TEE allowed for direct measurement of effective regurgitant orifice area (EROA), which differed significantly from calculated EROA (p &lt; 0.05).

Conclusion

3D-TEE is highly comparable to MSCT and superior to 2D imaging for the determination of TV geometry and diameters. In contrast to MSCT, 3D-TEE allows sufficient grading and functional assessment of TR.

P985 The use of strain analysis in patients under cardiotoxic chemotherapy: possible early detection of cardiotoxicity

Cardiotoxicity is a frequent side effect of chemotherapy leading to impaired outcomes in cancer survivors. Because of that cardiooncology has recently gained more importance in clinical practice. We aim to echocardiographically evaluate the development of cardiotoxicity and to detect early signs for preventing severe cardiomyopathies by repeated strain analysis.

We included 80 patients (46.7 ± 14.7 years, 75% female) under diverse cardiotoxic chemotherapies (43.7% breast cancer, 43.7% haematological malignancy, 12.5% others). All patients underwent echocardiography before and during treatment. Follow-up echocardiography was performed approximately 5.5 ± 1.2 months after the first application of the chemotherapy. The apical four-chamber view was used to perform strain analysis employing dedicated and automated offline software as shown previously.

Eight patients deceased due to oncological complications during follow up. Twelve patients showed significant reduced left ventricle ejection fraction (LVEFbaseline 63.2 ± 4.5%, LVEFFollow-up 48.6 ± 7.8%, p = 0.02) correlated with decrease in left ventricular global longitudinal strain (LV-GLSbaseline 17.1 ± 5.2%, LV-GLSFollow-up 9.7 ± 3.2%, p = 001). All of these patients presented heart failure symptoms, mostly with dyspnoea (85% functional NYHA class &gt; II) and oedema (65%). In 15 patients we found a reduction of left ventricular global longitudinal strain from &lt;5% without relevant reduction of LVEF. However, these patients showed also heart failure symptoms. During follow up 20 patients had to be admitted due to decompensated heart failure. Four patients deceased due to cardiovascular causes.

Delta LV-GLS (LV-GLSbaseline – LV-GLSFollow-up) was found to be strongest independent predictor of mortality. Baseline LV-GLS &lt; 15% was found to be associated with mortality and frequent rehospitalisation.

Solely LVEF is insufficient to detect cardiotoxicity and to estimate prognosis of patients under cardiotoxic chemotherapy. In our small patient collective we found baseline LV-GLS &lt;15% to be an adequate parameter for prognosis estimation and delta LV-GLS &gt; 5% a strongest independent predictor for mortality in patients with preserved LVEF under cardiotoxic chemotherapy.

P908 The novel predictor for mortality in patients with functional mitral regurgitation: the modified MIDA-Score

EuroSCORE and STS-Score are used to assess surgical risk in patients with valvular heart diseases. The MIDA- Score has been recently published as a representative predictor for short- and long-term prognosis in patients with degenerative mitral regurgitation (DMR). The adequate assessment of long-term prognosis in patients with functional MR is scarce. We aim to adapt this classical score system for patients with FMR.

We retrospectively included 105 patients with FMR who underwent transcatheter mitral regurgitation therapy (TMVR) between January 2014 and August 2016 in our center. Due to the different underlying pathomechanisms of FMR, annular dilatation and impaired left ventricle function, and more elderly patient population we adapted some cut-off values to FMR patients (Age &gt; 65 to Age &gt; 75; LV-EF ≤ 60% to LV-EF ≤ 45%; sPAP≥50mmHg to sPAP≥45mmHg). Moreover, according to Cox proportional hazard analysis of our patient collective we re-calculated the weights of the risk factors: Age 2 points, Symptoms 1 point, atrial fibrillation 2 points, left atrial diameter 1 point, right ventricle systolic pressure 2 points, left ventricle end-systolic diameter 2 points, left ventricle ejection fraction 2 points. We defined three risk groups according to total points from the risk factors; Grade 1 (0-4 points): low risk, Grade 2 (5-9 points): moderate risk, Grade 3 (10-12 points): high risk.

We retrospectively included 105 patients (76.7 ± 8.8 years, 50,6% female) with symptomatic (functional NYHA class &gt; II ) moderate-to-severe FMR (PISA: 0.7 ± 0.4cm, VC width: 0.8 ± 0.3cm, EROA: 0.22cm2, RegVol: 38.1 ± 19.2ml) at surgical high risk (EuroSCORE II: 5.4 ± 3.8%, STS-Score: 4.7 ± 2.8%). We found all-cause mortality 7% at one-year follow-up. 34.1% of our collective were hospitalized.

The classical MIDA Score was not significantly correlated with mortality and rehospitalization in patients with FMR at follow-up (p = 0.5); however, the modified MIDA score was found to be a strong predictor for mortality and rehospitalization in patients with FMR (AUC: 0.89). According to multivariate analysis, the modified MIDA score was found to be superior compared to the other conventional score systems (The modified MIDA-Score HR: 4.1, p = 0.021; EuroSCORE II; HR: 1.2, p = 0.004, STS-Score; HR: 1.7, p = 0.005).

We performed Cox proportional hazard analysis to assess the weighting factor of the predictors. As a result of this, we found age (HR: 2,95, p = 0.03) as the most reliable parameter to predict the combined outcome.

The 12,5% of grade 1, 27% grade 2, 57% grade 3 patients showed combined endpoint. According to regression analysis, the modified score &gt;9 points found to be a strong predictor for high mortality and rehospitalization (OR: 3.35, p = 0.011).

We found the modified MIDA Score sufficient and extensive to assess outcomes in patients with FMR. The modified MIDA Score offers a sufficient promising tool to predict individual prognosis in patients with FMR.

43 Echocardiographical analysis of right ventricular function after transcatheter edge-to-edge repair of tricuspid regurgitation

Tricuspid regurgitation (TR) is a frequent valvular heart disease associated with increased mortality and morbidity. RV function is mostly assessed using tricuspid annulus plane systolic excursion (TAPSE), which shows merely systolic RV function and can be influenced by many other pathologies and image quality. Furthermore, the impact of dedicated percutaneous clip treatment of TR on RV global function and clinical outcomes are scarce.

We aim to perform detailed echocardiographical global RV function analysis inclusively speckle tracking of RV before and after transcatheter edge-to-edge repair of TR (TTVR).

We evaluated 50 patients, who underwent between January 2017 to March 2018 TTVR in our center. Apical four chamber images were used to perform strain analysis of RV. The systolic velocity of free RV wall (S´ Vmax) was measured through PW doppler on lateral TV annulus in color tissue Doppler. RV myocardial performance index is a parameter for systolic as well as diastolic ventricle function and can be calculated using ratio between TV closure to opening time and RV ejection time (RVCOT-RVET/RVET), which can be assessed from PW Doppler of lateral TV annulus in color tissue Doppler.

We retrospectively included 40 patients (73 ± 5.6 years, 32% female) with symptomatic (65% ascites, 95% edema, 100% NYHA &gt; II) high grade functional TR at surgical high risk (EuroSCORE II: 7.6%). 95% of all interventions were successfully performed (TR reduction at least I grade).

Our collective shows normal baseline left ventricle (LV) systolic function (Ejection fraction: 60.8 ± 4.6%) with diastolic LV dysfunction and increased LV end systolic pressure (E/E´ ratio: 17.7 ± 6.5). Baseline RV analysis presented impaired RV systolic function (TAPSE: 1.2 ± 3.2 cm, RV-FAC: 25.6 ± 9.8%, S´ Vmax: 5.6 ± 1.2cm/s) with decreased RV global longitudinal strain (RV-GLS: -8.9 ± 4.3). RV myocardial performance index (RV-MPI) was 0.51 ± 0.4 as a parameter for poor global RV function. Baseline echocardiography showed dilation of both atria (Left atrium: 80.5 ± 14.5ml, right atrium: 26.7 ± 7.8cm2) with pronounced right ventricle congestion (dilated vena cava inferior: 25.5 ± 3.4mm without breath modulation, paradoxical intraventricular septum motion, dilated RV: 57.7 ± 14.5cm2). All TR were high grade (PISA: 0.78 ± 0.3cm, VC width: 0.8 ± 0.2cm, EROA: 0.43 ± 0.1cm2, regurgitant volume: 67.1 ± 10.4ml) and functional with mostly anteroseptal (85%) coaptation defect (coaptation defect diameter: .5.7 ± 3.2mm).

The right heart failure symptoms significantly improved three months after the procedure. Patients with severe right heart failure (TAPSE &lt; 1cm) showed more often rehospitalization and limited improvements in symptoms (p = 0.02).

RV function should be more comprehensively evaluated before interventional TR therapy. The patients with already preprocedural severe right heart failure should be more critically discussed. RV-GLS and RV-MPI are strongest independent parameter of clinical outcome after TTVR.

422 Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve

The MitraClip procedure is established as a therapeutic alternative to mitral valve surgery for symptomatic patients with severe mitral regurgitation (MR) at prohibitive surgical risk. In this study, we aimed to evaluate five-year outcomes after MitraClip.

265 patients (Age: 81.4 ± 8.1 years, 46.7% female, logistic EuroSCORE: 19.7 ± 16.7%) with symptomatic MR (60,5% secondary MR: sMR) undergoing MitraClip were included. Despite procedural success of 91.3%, patients with primary MR (pMR) had a higher rate of procedural failure (sMR: 3.1%, pMR: 8.6%; p = 0.04).

Five years after MitraClip, the majority of patients presented with reduced symptoms, sustained MR reduction (≤ grade 2) and improved functional capacity (Functional NYHA class: p = 0.0001; six minutes walking test: p = 0.04) and right ventricular (RV) function.

Systolic pulmonary artery pressure (sPAP) was significantly reduced during FU only in sMR patients, (p = 0.05, p = 0.3). Despite a pronounced clinical and echocardiographical amelioration and low interventional failure, five-year mortality was significantly higher in patients with sMR (p = 0.05). The baseline level of creatinine (HR: 0.695), sPAP (HR: 0.96) and mean mitral valve gradient (HR: 0.82) were found to be independent predictors for poor functional outcome and mortality.

MitraClip showed low complication rates and sustained MR reduction with improved RV function and sPAP five years after the procedure, which was found in all patients, predominantly in patients with sMR. Despite pronounced functional amelioration with low procedure failure, sMR patients had higher five-year mortality and worse outcomes. Baseline creatinine, MVG, and sPAP were found to be independent predictors of poor functional outcomes and five-year mortality.

425 Alterations in left atrial structure and function in chronic heart failure patients with functional mitral regurgitation after MitraClip

Backround

The MitraClip procedure has been increasingly performed as an established treatment alternative for symptomatic patients with moderate to severe mitral regurgitation (MR) at prohibitive surgical risk. Left ventricular (LV) reverse remodelling following MitraClip has been shown in different studies. Left atrial (LA) volumes are believed to decrease following interventional reduction of MR. However, effects of MitraClip on LA function are not well understood.

Objectives

In this study we aimed to evaluate the effect of MitraClip on LA structure, volumes and function in chronic heart failure patients with functional MR.

Methods

All patients underwent 3D transthoracic echocardiography prior to the MitraClip procedure and at follow-up (FU) with offline evaluation of LA function and geometry using dedicated software (TomTec Image Arena, 4D LV-Analysis, Munich, Germany). FU examinations were performed 10 ± 3.4 months after the procedure.

Results

We prospectively included 75 consecutive surgical high risk (Logistic EuroScore: 17.2 ± 13.9%) patients (Age: 77 ± 9years, 22% female) with symptomatic moderate to severe MR without atrial fibrillation. All patients underwent MitraClip following heart team decision without periinterventional major complications.

Baseline echocardiography showed impaired left ventricular function (Ejection fraction (EF): 32,6 ± 11.2%), moderate to severe MR , increased systolic right ventricle pressure (RVSP: 46.1 ± 10.5 mmHg) and elevation in estimated left ventricle enddiastolic pressure (E/E´ ratio: 15.6 ± 7.3) in the patient cohort.

There was no relevant mitral stenosis after the procedure (MPG: 3.3 ± 0.5 mmHg), however the MPG increased significantly after the procedure (p = 0.05). The E/E´ ratio significantly increased at FU (15.6 ± 7.3, 24.1 ± 13.2, p = 0.05) as well. The left atrial (LA) volumes and LA-muscular mass (End-diastolic volume [LA-EDV] and end-systolic volume [LA-ESV]) significantly increased at FU (LA-EDV: 83.1 ± 39.5ml, 115.1 ± 55.3ml, p = 0.012; LA-ESV: 58.4 ± 33.4ml, 80.1 ± 43.9ml, p = 0.031; 105.1 ± 49.3gr, 145.4 ± 70.6gr, p = 0.013). LA stroke volume significantly increased after the procedure (24.6 ± 12.5ml, 34.9 ± 19.1ml, p = 0.016). LA-EF and atrial global longitudinal strain (LA-GLS) showed no significant changes at FU (LA-EF: 31.7 ± 12.8%, 31.1 ± 12.3%, p= 0.8; LA-GLS: -10.8 ± 5.4%, -9.7 ± 4.45%, p = 0.4).

Despite no relevant changes during FU, baseline E/E´ ratio (AUC: 0.652) and baseline aGLS (AUC: 0.694) were found to be independent predictors for mortality.

Conclusion

Transcatheter MV repair (TMVR) with the MitraClip procedure improves atrial stroke volume, increases atrial volumes and muscular mass acutely after the procedure. It might be explained by the acutely increased MPG and LVEDP after the MitraClip procedure. Baseline aGLS and E/E´ ratio were found to be independent predictors for mortality.

International study on nurses' views and experiences of compassion

BACKGROUND

Compassion is considered the cornerstone of nursing practice. However, the recent failures in delivering high-quality compassionate nursing care in the UK's National Health Service have brought the topic of compassion to the attention of the public, service providers, policy makers and academics.

AIM

The aim of this study was to explore the nurses' views and experiences of a number of compassion-related issues in nursing and describe similarities and differences at an international level as well as from the different nursing roles of the participating nurses.

METHODS

An exploratory, cross-sectional descriptive study, using the International Online Compassion Questionnaire. A total of 1323 nurses from 15 countries completed the questionnaire.

RESULTS

The majority of participants (59.5%) defined compassion as "Deep awareness of the suffering of others and wish to alleviate it" but definitions of compassion varied by country. Of participants, 69.6% thought compassion was very important in nursing and more than half (59.6%) of them argued that compassion could be taught. However, only 26.8% reported that the correct amount and level of teaching is provided. The majority of the participants (82.6%) stated that their patients prefer knowledgeable nurses with good interpersonal skills. Only 4.3% noted that they are receiving compassion from their managers. A significant relationship was found between nurses' experiences of compassion and their views about teaching of compassion.

CONCLUSION

Our study is unique in identifying the views and experiences of nurses from 15 different countries worldwide. The findings reveal that compassion is neither addressed adequately in nursing education nor supported in the practice environment by managers.

LIMITATIONS

Self-report bias was inherent to our survey study design. Furthermore, the individual cultural differences and similarities in the findings are difficult to extrapolate owing to the fact that our analysis was at country level, as well as at the level of the participating nurses.

IMPLICATIONS FOR NURSING POLICY

Understanding the influence of culture on nurses' views about compassion is critical in the current multicultural healthcare environment and merits further research. This will potentially drive changes in nursing education (ensuring that compassion is taught to nurses) and in the way healthcare leaders and managers foster a compassionate culture within their organizations (e.g. by leading by example and compassionate to their staff).

Effects of different cavity-disinfectants and potassium titanyl phosphate laser on microtensile bond strength to primary dentin

AIM

The aim of this in vitro study was to compare the effects of different cavity-disinfectants and potassium titanyl phosphate (KTP) laser on microtensile bond strength to primary dentin. Chlorhexidine (CHX), propolis (PRO), ozonated water (OW), gaseous ozone (OG) and KTP laser were used for this purpose.

METHODOLOGY

Twelve primary molar teeth were used in this study. One-third of the teeth (from coronal portion) were removed to obtain flat surfaces. After applying the cavity-disinfectants, an adhesive (prime and bond NT) was applied to dentin surfaces, and composite crowns were built up. One group received no pretreatment and was set as a control (CONT). Ten sticks were obtained from these samples and were stressed in tension until failure using a universal testing machine and the data were recorded.

RESULTS

The mean strength values (in MPa) of the sticks were OW (11.12) > KTP (9.58) > CHX (7.58) > PRO (7.42) > CONT (6.38) > OG (5.84) and OW showed significantly higher results than the other groups, except KTP group (P < 0.05).

CONCLUSIONS

OW and KTP might be used safely without compromising the bond strength of restorative materials.

Thrombolytic therapy in a patient with inferolateral myocardial infarction after carbon monoxide poisoning

INTRODUCTION

ST segment elevation myocardial infarction (STEMI) due to coronary artery occlusion caused by intracoronary thrombosis in the setting of acute carbon monoxide (CO) poisoning is a very rare presentation. We present a case of intracoronary large and mobile thrombus formation after CO poisoning.

CASE PRESENTATION

A previously healthy 50-year-old woman was referred for CO poisoning. She had chest pain after exposure to CO. Her initial mental status was preoccupied with chest pain. Her initial CO fraction was 28.1%, and initial laboratory data showed creatine kinase-myocardial isoenzyme of 134 U/L (upper limit 25 U/L) and troponin I of >50 ng/mL (upper limit 0.06 ng/mL). Electrocardiography was carried out on admission, revealing an ST segment elevation in the inferolateral leads. After initial evaluation, coronary angiography was performed and an intracoronary large mobile thrombus was seen in the proximal left anterior descending (LAD) artery with no significant stenosis. We administered tenecteplase with heparin. After the thrombolytic therapy, ST elevation in the inferolateral leads resolved. Repeat angiography was performed after 24 h; the thrombus in LAD had resolved. The patient was discharged after 5 days, with persistent Q wave in the inferior leads and mild hypokinesia of the inferoposterior wall suggesting myocardial injury.

CONCLUSION

We describe intracoronary thrombus formation induced by CO poisoning. Because intracoronary thrombus can result in myocardial infarction, its consideration following CO poisoning is important. Patients with CO poisoning who have symptoms of STEMI should be carefully evaluated with serial electrocardiograms, cardiac biomarkers, and an echocardiogram. When there is evidence of acute myocardial injury, a primer in coronary angiography can determine which patients could benefit from intervention.

Accuracy of three different apex locators and visual exam in primary teeth with and without root resorption in vitro

AIM

The aim of this study was to evaluate the accuracy and reliability of three apex locators (EndoMaster, Raypex, DentaPort ZX) and visual assessment in primary molar teeth in vitro.

MATERIALS AND METHODS

Twenty-four extracted human primary molar teeth with and without root resorption were used in this study. After endodontic access preparation, root canal length was visually measured by means of a K file; then the teeth were embedded into alginate and the roots were measured again by mans of the three apex locators. The results were collected in SPSS 15.0 and statistical evaluations were completed by one-way ANOVA and Kruksal-Wallis test.

RESULTS

The measurements closest to the visually determined length were obtained with EndoMaster. No statistically significant differences were found between visual and apex locators lengths (p>0.05).

CONCLUSION

Within the limitations of this study, the use of apex locators would be useful in the endodontic treatment of primary teeth.

Do elevated serum IgM levels have to be included in probable diagnosis criteria of patients with ataxia-telangiectasia?

Ataxia-telangiectasia (AT) is a rare multisystem, neurodegenerative genetic disorder that is characterised by progressive neurological abnormalities, oculocutaneous telangiectasias and immunodeficiency. Delay in diagnosis or misdiagnosis is probable due to its wide clinical heterogeneity in infancy. Recurrent sinopulmonary infections are often the only presenting symptom and usually patients have decreased immunoglobulins. A total 10% of patients who present with decreased serum immunoglobulin G and A and with normal or elevated immunoglobulin M levels are often misdiagnosed as hyperimmunoglobulin M syndrome. Definitive diagnosis is made if a patient with progressive cerebellar ataxia has a disease causing mutation on the ATM gene. Ataxia-telangiectasia guideline of the European Society for Immunodeficiencies defines the probable diagnosis criteria. We evaluated twenty ataxia-telangiectasia patients (mean age 13.8±4.1 years) retrospectively who were followed-up for a mean of 38.6±27.0 months. Twelve patients had a family history of consanguinity. A total of 80&#x0025; patients suffered from various infections. Neoplasms occurred in three of them. Patients showed immunological abnormalities as low IgG (45%), low IgA (65%) and elevated IgM (60%) levels. CD3+CD4+ T lymphocyte frequency was low in 45% patients. The mean AFP concentration at the diagnosis was 191.9±140.1 ng/mL and the raised IgM values did not show any statistically significant relationship with high AFP concentrations. Frequency of the elevated IgM concentrations in (60%) patients raises the concerns about thinking this finding has to be accepted as a probable diagnosis criterium.

Relationship between primary lesion metabolic parameters and clinical stage in lung cancer

OBJECTIVES

The relation of PET-derived parameters as maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG), metabolic tumor volume (MTV) with clinical stage in lung cancer and correlation of SUVmax of primary tumor and that of metastatic lesion was studied in lung cancer patients.

MATERIALS AND METHODS

Patients with lung cancer who were referred for FDG PET/CT were included in the study.

RESULTS

PET/CT scans and pathology reports of 168 patients were assessed. A total of 146 (86.9%) of these patients had a diagnosis of non-small cell lung cancer (NSCLC) and 22 (13.1%) had small cell lung cancer (SCLC). Metabolic parameters such as SUVmax, TLG and MTV showed significant differences in all the stages in NSCLC patients (p<0.001). However, after tumors sizes <25 mm were excluded, no significant differences in SUVmax between stages were observed. No significant differences were found between these metabolic parameters and limited or extended disease SCLC. Tumor diameter correlated with primary tumor SUVmax and significant correlations between primary lesion SUVmax and metastatic lesion SUVmax were found.

CONCLUSIONS

Although differences were found regarding indices between stages of NSCLC cases, SUVmax differences between stages seem to be caused by underestimation of SUVmax in small lesions. Other glucose metabolism indexes such as MTV and TLG show promising results in terms of prognostic stratification. Future studies are needed for better understanding of their contribution to clinical cases.

Is QUALIOST appropriate for the patients with orthotopic liver transplantation in measuring quality of life?

The quality of life questionnaire in osteoporosis (QUALIOST) measures the impact of this condition. The purpose of this study was to assess the psychometric properties of QUALIOST among 38 orthotopic liver transplantation (OLT) patients who had been diagnosed with osteoporosis or osteopenia versus 42 control subjects with osteoporosis or osteopenia associated with other conditions. Bone mineral density (gr/cm(2)) measurements were performed by dual-energy X-ray absorptiometry as well as thoracic and lumbar spine radiographs to assess fractures. Reliability studies evaluated by intraclass correlation coefficients (ICC) and internal consistency (Cronbach α). For the validity studies, correlation analysis was performed between this scale and Short Form-36 (SF-36) results. The questionnaire was filled out completely by all the patients with 0.9% and 1.3% of omitted answer rates for OLT and control patients. ICC and Cronbach's α values were good for all domains with values above .90. In both groups we observed significant negative high correlations between the domains of the questionnaire and all SF-36 dimensions (P < .001). At least one vertebral fracture was diagnosed in 17 (44.7%) and 20 (47.6%) patients with OLT and control respectively. The comparison analysis revealed that the scores of QUALIOST of patients with vertebral fracture were significantly higher than those without a fracture in both groups (P < .05). In conclusion, we evaluated the validity and reliability of a scale measuring quality of life in patients who had osteoporosis secondary to OLT. The results showed that the Turkish QUALIOST showed acceptable validity and reliability in these patients.

Evaluation of changes in quality of life among Turkish patients undergoing ventricular assist device implantation

BACKGROUND

Ventricular assist device (VAD) application has become an increasingly common method to treatment end-stage heart failure. In this study we evaluated the effect of VAD implantation upon the quality of life among Turkish patients with end-stage heart failure.

METHODS

Twenty-eight VAD implantation patients included 3 (10.7%) with biventricular support using the Berlin Heart Excor; 15 (53.6%), left ventricular support with the Berlin Heart Excor; and 10 (35.7%), Heartware implantation for left ventricular support. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and Short Form 36 (SF-36) Health Questionnaire were used to assess changes in the quality of life (QOL).

RESULTS

Of the 28 patients, 2 were females (7.1%) and 26 were males (92.9%) of overall mean age of 44.6 ± 15.3 years (range, 8-66). Preoperative mean score of MLHFQ was significantly improved at 200.4 ± 147.4 days follow-up (72.8 ± 11.5 vs 13.7 ± 10.5; P < .05). SF-36 physical scores and mental scores were improved postoperatively (physical scores, 20.0 ± 24.4 vs 70.2 ± 19.9; mental scores, 38.4 ± 18.8 vs 73.9 ± 15.7; P < .05). No significant relation was observed between the postoperative scores of questionnaires and type of surgery. More improvement in postoperative MLHFQ scores was seen in patients younger than 45 years of age (P = .027). The severity of chronic heart failure (CHF) regressed from New York Heart Association (NYHA) class IV to NYHA class II in 26 and to NYHA class III in 2 patients (P = .000).

CONCLUSION

The QOL among patients with end-stage heart failure improved dramatically soon after VAD implantation.

Expectant management of preterm premature rupture of membranes remote from term with exiguous amniotic fluid and a prolonged latency period: report of two cases

Management of preterm premature rupture of membranes (PPROM) is a very challenging issue for the obstetricians. We report two cases of PPROM occurring in early gestation remote from term (both < 26 weeks) with exiguous amniotic fluid (amniotic fluid index of < or =2 cm) that were managed successfully by conservative treatment and resulted in a latency period of almost two months. This treatment option might be feasible in carefully selected patients following meticulous evaluation and warrants further research.

Reduced gray matter volume in the frontotemporal cortex of patients with early subacute sclerosing panencephalitis

BACKGROUND AND PURPOSE

Subacute sclerosing panencephalitis (SSPE) is a persistent infection of the central nervous system by the measles virus. Patients in the initial stages of SSPE show behavioral symptoms and usually normal cranial MR imaging findings. We aimed to investigate the gray matter volume changes in patients with early SSPE.

MATERIALS AND METHODS

Seventeen patients with SSPE with normal cranial MR imaging findings and 30 sex- and age-matched control subjects were included in the study. Clinical parameters of the patients were quantified by using a neurologic disability index (NDI) as defined previously. We obtained T1-weighted magnetization-prepared rapid acquisition gradient echo images from the patients and control subjects, and we applied an optimized method of voxel-based morphometry. We performed a cross-sectional analysis to search the gray matter volume differences between the patients and control subjects. The correlation between the gray matter distribution and the duration of symptoms, immunoglobulin G index, and NDI scores was tested.

RESULTS

We found that the cortical gray matter volume of patients was reduced in the frontotemporal regions including the bilateral cingulate cortex and amygdala. There was no correlation between the gray matter distribution of patients and the duration of symptoms or the NDI scores.

CONCLUSIONS

The current study demonstrated gray matter volume reduction in the frontotemporal cortex of patients with SSPE without any apparent lesions on conventional MR imaging. Because the cingulate cortex and amygdala are involved in emotion processing, gray matter loss in these regions may contribute to the development of early behavioral symptoms of SSPE.

Multimodal investigation of fMRI and fNIRS derived breath hold BOLD signals with an expanded balloon model

Multimodal investigation of blood oxygenation level-dependent (BOLD) signals, using both functional near-infrared spectroscopy (fNIRS) and functional magnetic resonance imaging (fMRI), may give further insight to the underlying physiological principles and the detailed transient dynamics of the vascular response. Utilizing a breath hold task (BHT), we measured deoxy-hemoglobin (HbR) and oxy-hemoglobin (HbO) changes via fNIRS and blood oxygen level dependent (BOLD) changes by fMRI. Measurements were taken in four volunteers asynchronously and carefully aligned for comparative analysis. In order to describe the main stimulus in BHT, partial pressure of carbon dioxide (PaCO(2)) parameter was integrated into the balloon model as the driving function of cerebral blood flow (CBF) which led to the development of an expanded balloon model (EBM). During BHT, the increase in HbR was observed later than the BOLD peak and coincided temporally with its post-stimulus undershoot. Further investigation of these transients with a PaCO(2) integrated balloon model suggests that post-stimulus undershoot measured by fMRI is dominated by slow return of cerebral blood volume (CBV). This was confirmed by fNIRS measurements. In addition, the BOLD signal decreased with the increase of the initial level of PaCO(2) derived from EBM, indicating an effect of basal CBF level on the BOLD signal. In conclusion, a multimodal approach with an appropriate biophysical model gave a comprehensive description of the hemodynamic response during BHT.

Increased gray matter density in the parietal cortex of mathematicians: a voxel-based morphometry study

BACKGROUND AND PURPOSE

The training to acquire or practicing to perform a skill, which may lead to structural changes in the brain, is called experience-dependent structural plasticity. The main purpose of this cross-sectional study was to investigate the presence of experience-dependent structural plasticity in mathematicians' brains, which may develop after long-term practice of mathematic thinking.

MATERIALS AND METHODS

Twenty-six volunteer mathematicians, who have been working as academicians, were enrolled in the study. We applied an optimized method of voxel-based morphometry in the mathematicians and the age- and sex-matched control subjects. We assessed the gray and white matter density differences in mathematicians and the control subjects. Moreover, the correlation between the cortical density and the time spent as an academician was investigated.

RESULTS

We found that cortical gray matter density in the left inferior frontal and bilateral inferior parietal lobules of the mathematicians were significantly increased compared with the control subjects. Furthermore, increase in gray matter density in the right inferior parietal lobule of the mathematicians was strongly correlated with the time spent as an academician (r = 0.84; P < .01). Left-inferior frontal and bilateral parietal regions are involved in arithmetic processing. Inferior parietal regions are also involved in high-level mathematic thinking, which requires visuospatial imagery, such as mental creation and manipulation of 3D objects.

CONCLUSION

The voxel-based morphometric analysis of mathematicians' brains revealed increased gray matter density in the cortical regions related to mathematic thinking. The correlation between cortical density increase and the time spent as an academician suggests experience-dependent structural plasticity in mathematicians' brains.

Pulmonary cement embolism: a complication of percutaneous vertebroplasty

BACKGROUND

Percutaneous vertebroplasty (PV) has recently become a very common procedure for vertebral compression fractures. Extravasation of cement, a common event associated with vertebroplasty, may lead to cement emboli in the lungs.

PURPOSE

To determine the frequency of pulmonary cement embolism after percutaneous vertebroplasty.

MATERIAL AND METHODS

Between 2002 and 2006, 128 percutaneous vertebroplasties were performed in 73 patients (56 women and 17 men) in our institution. Postprocedural chest radiographs were obtained for all patients and assessed for the presence of pulmonary cement emboli.

RESULTS

Pulmonary cement embolism was detected on chest radiographs and confirmed with chest computed tomography (CT) in four patients treated with percutaneous vertebroplasty for osteoporotic collapse and one patient treated for multiple myeloma. The imaging finding of pulmonary cement embolism was solitary or multiple fine radiodense lines with occasional branching patterns. The frequency of pulmonary cement embolism was 6.8%.

CONCLUSION

An incidence of pulmonary cement embolism of 6.8% during PV was found. Close clinical follow-up, postprocedural chest radiographs, and chest CT scans, if necessary, are important for the detection of pulmonary cement embolism at an early stage.

A new material for prevention of peritendinous fibrotic adhesions after tendon repair: oxidised regenerated cellulose (Interceed), an absorbable adhesion barrier

In this experimental study, we aimed to examine the ability of absorbable oxidised regenerated cellulose (Interceed, TC-7, Johnson & Johnson, USA) to inhibit the formation of peritendinous fibrotic adhesions after tendon repair in rats. Both Achilles tendons of 23 female Wistar-Albino rats weighing between 350 and 450 grams were cut and repaired. On the right side, Interceed absorbable adhesion barriers were wrapped around the repaired tendon (group I). On the left, the same procedures were applied except for the Interceed wrapping and these were grouped as control (group II). Animals were sacrificed at postoperative day 28 and macroscopic and histological examination was performed. All the animals survived and no tendon rupture was observed. No wound dehiscence, wound infection or exposure of repaired tendons occurred. Macroscopically, there were three (13.1%) tendons without adhesion formation and 20 (86.9%) tendons with inferior adhesion formation in group I; on the other hand, there were 16 tendons (69.5%) with medium grade adhesion formation and seven tendons (30.5%) with severe peritendinous adhesion formation in group II (control group) (p<0.05). Histologically, adhesion formation was absent in 11 tendons (47.8%) and slight in 12 tendons (52.2%) in group I; while in group II, it was slight in two (8.6%), moderate in 15 (65.2%) and severe in six tendons (26.2%) (p<0.05). Sixteen (69.5%) of 23 tendons in group I and 11 (47.8%) of 23 tendons in group II showed no inflammatory reaction (p<0.05). Nineteen (82.6%) tendons in group I and only one tendon in group II showed excellent to good tendon healing (p=0.00). According to our results, we feel that Interceed may have an intraoperative role to play in the reduction of adhesions after surgical tendon repair. This study suggests that absorbable oxidised regenerated cellulose merits further evaluation as a potential treatment to inhibit the formation of peritendinous adhesions. Rigorous and extensive controlled trials should be undertaken on patients undergoing tendon repair with or without this barrier.

A new classification and guide for surgical treatment of spinal tuberculosis

So far, there is no widely accepted classification system based on objective findings that can serve as a guide in selecting the treatment method for spinal tuberculosis. This retrospective study evaluates patients with spinal tuberculosis (Pott's disease) treated with different surgical procedures. Our aim was to outline a new classification of spinal tuberculosis. A retrospective review of 76 cases (55 male and 25 female patients) of spinal tuberculosis was conducted. Five of the patients were treated medically, and the others who were treated surgically were classified into three types (I, II and III) according to the new classification system for spinal tuberculosis. All 76 patients were classifiable by this new system. The most common complication observed was local kyphosis (maximum 8 degrees) in type-II patients, but none of the patients needed correction. No neurological deterioration was observed in any of the cases. This new classification system helps in differentiating the various manifestations of spinal tuberculosis and appears to correlate with the surgical treatment of spinal tuberculosis. We believe that this new classification system can be used as a practical guide in the treatment of Pott's disease.

Tuberculosis of the lumbar spine: outcomes after combined treatment of two-drug therapy and surgery

This article evaluates complications and treatment results in patients with tuberculosis of the lumbar spine. Eighteen patients with active tuberculosis of the lumbar spine were treated surgically in the orthopedic surgery department at Uludag University School of Medicine between 1993 and 2000. All patients received antituberculosis combination drug therapy (isoniazid and rifampicin) for 9 months. Patients who underwent anterior radical debridement and anterior fusion and/or posterolateral debridement and posterior fusion plus stabilization showed 5-8 degrees correction of local angulation after surgery. The mean loss of correction at final follow-up (mean: 5 years) in anterior or posterior surgery alone was 45%-50%, whereas the corresponding finding for the combined approach was 12%. The combination of two-drug chemotherapy (daily isoniazid and rifampicin for 9 months) and surgery is effective for tuberculosis of the lumbar spine.

Traumatic Nerve Root Avulsion and Pseudomeningocele Diagnosed by Three Dimensional MRI Technique (CISS Sequence)

This case report demonstrates the importance of the CISS sequence, a fast imaging technique in MRI, in case of suspected nerve root avulsion. We present a case of traumatic pseudomeningoceles at T1-T2 root levels with right T2 ventral root avulsion without associated skeletal fracture diagnosed by MRI using the three dimensional CISS technique. A 28-year-old man presented to the Emergency Department following a motorcycle accident. Clinical examination revealed paresis in intrinsic muscles of the right hand. Traumatic pseudomeningoceles at T1-T2 root levels bilaterally with right T2 ventral root avulsion without associated skeletal fracture were diagnosed by three dimensional cervicothoracic MRI with CISS technique.

"Sandwich technique" in the surgical treatment of primary complex fractures of the femur and humerus

In this prospective study, our aim was to determine the clinical and radiographic outcomes of the surgical treatment of primary complex problem femoral and humeral shaft fractures treated by a new technique called "sandwich technique." A total of 45 patients with comminuted, complex and/or osteopoenic fractures of the femur or humerus (30 femoral and 15 humeral fractures) were treated using this technique. The patients were followed up for a mean of 25 months. In 24 (85.7%) of 28 patients with femoral fractures and in 14 (93.3%) of 15 patients with humeral fractures, union was achieved within 3-6 months of the operation (mean: 4.5 months). The total union rate was 88.4%. The pseudoarthrosis rate was 12%. There was no infection or implant failure seen during the follow-up period. The cortical allograft struts can be used to provide collateral support to weakened osteopoenic/osteoporotic bone. This technique provides a union rate of about 88% in osteoporotic and/or complex primary humerus or femur fractures.