AB1317 SERUM INTERLEUKIN 37 LEVELS IN FAMILIAL MEDITERRANEAN FEVER PATIENTS AND ASSOCIATION WITH CLINICAL FEATURES

Background

Familial Mediterranean Fever (FMF) is the most common form of autoinflammatory diseases that is characterized by febrile episodes of serositis, arthritis and skin rash (1). Mutations in MEFV gene causes dysfunction of pyrin inflammasome, ultimately resulting in over-activation of Caspase-1 which is responsible for catalytic activation of interleukin (IL)-1 beta and gasdermin-D (2). IL-37 is also one of the IL-1 cytokines activated by caspase-1 acting as natural inhibitor of inflammation (3).

Objectives

IL-37 has pathogenetic roles for certain inflammatory diseases. We aimed to investigate serum IL-37 levels and its relationship with clinical and laboratory features of disease.

Methods

58 adult patients diagnosed with FMF according to Tel Hashomer criteria were included. Thirty subjects were served as healthy control subjects. Demographic, genetic, clinical and laboratory features and treatment responses of patients were recorded. Twenty-nine patients were colchicine responsive whereas 29 were colchicine refractory. Serum IL-37 levels were measured by ELISA from blood samples obtained at attack free periods.

Results

Peritonitis was the most common attack type (81%) followed by fever (80%) and arthritis (67%). There was no difference between FMF patients and healthy subjects for their serum IL-37 levels. A negative correlation was found between IL-37 values ​​and erythrocyte sedimentation rate in FMF patients (r: -0,31; p:0.015). IL -37 level was found to be significantly lower in patients who suffer from arthritis (median [IQR] 119 [396] ng/L vs 53 [164] ng/L, p= 0.03), myalgia (147 [364] ng/L vs 53 [84] ng/L, p= 0.05) or skin rash (102 [360] ng/L vs 54 [130] ng/L, p= 0.05) compared to those who did not have these attacks.

Conclusion

Although there was no difference in serum IL-37 levels between FMF patients and healthy subjects, IL-37 seem to be associated with musculoskeletal and skin attacks of FMF. Further research is needed to determine whether IL-37 have relationships with other features of FMF such as spondyloarthritis and febril myalgia.

References

[1]El-Shanti H, Majeed HA, El-Khateeb M. Familial mediterranean fever in Arabs.Lancet. 2006;367(9515):1016–24.

[2]Kanneganti A, Malireddi RKS, Saavedra PHV, Vande Walle L, Van Gorp H, Kambara H, Tillman H, Vogel P, Luo HR, Xavier RJ, Chi H, Lamkanfi M. GSDMD is critical for autoinflammatory pathology in a mouse model of Familial Mediterranean Fever. J Exp Med. 2018 Jun 4;215(6):1519-1529. doi: 10.1084/jem.20172060

[3]Nieman DC, Ferrara F, Pecorelli A, Woodby B, Hoyle AT, Simonson A, Valacchi G. Postexercise Inflammasome Activation and IL-1β Production Mitigated by Flavonoid Supplementation in Cyclists. Int J Sport Nutr Exerc Metab. 2020 Sep 15:1-9. doi: 10.1123/ijsnem.2020-0084.

Acknowledgements

No financial support is obtained from any company

Disclosure of Interests

None declared

AB1272 FACTORS AFFECTING PATIENT-ACCEPTABLE SYMPTOM STATES IN FAMILIAL MEDITERRANEAN FEVER

Background

Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent attacks of fever, serositis, and musculoskeletal symptoms (1, 2). Arthritis is the most common musculoskeletal symptom of attacks and also included in diagnostic criteria of FMF (3). If it is specifically queried, myalgia may be detected in up to 20-25% of the patients with FMF.(4,5).

Objectives

In our study, we aim to assess the localization of attack-related myalgia and associated parameters in patients with FMF.

Methods

A total of 349 consecutive patients followed by FMF in our clinic were enrolled in the study and asked for attack-induced myalgia and if present, localization of muscle groups on the mannequin body parts diagram.

Attack frequency, duration, and disease activity were evaluated with the AutoInflammatory Diseases Activity Index (AIDAI) scoring system (6). Patients were also asked for work/study day loss during attacks and patient acceptable symptom state (PASS) status (7).

Results

126 patients showed attack myalgia (36%); attack duration, frequency, severity were significantly higher in patients with attack-myalgia (p<0,005). Most common muscle groups were calves, lower back, and latissimus dorsi muscles in order. Myalgia was most commonly accompanied by arthritis (p<0,002). Patients with myalgia have a higher frequency of colchicine resistance and work/study day loss due to attacks.

Conclusion

Our results conclude that myalgia is an important domain of attacks and causes absenteeism and uncontrolled disease activity. Treatment of myalgia attacks may provide controlled disease activity, and prevent absenteeism from work/school.

References

[1]El-Shanti H, Majeed HA, El-Khateeb M. Familial mediterranean fever in Arabs.Lancet. 2006;367(9515):1016–24.

[2]Majeed HA, Al-Qudah AK, Qubain H, Shahin HM. The clinical patterns of myalgia in children with familial Mediterranean fever. Semin Arthritis Rheum. 2000;30(2):138–43.

[3]Gattorno M, Hofer M, Federici S, Vanoni F et al. Eurofever Registry and the Paediatric Rheumatology International Trials Organisation (PRINTO). Classification criteria for autoinflammatory recurrent fevers. Ann Rheum Dis. 2019 Aug;78(8):1025-1032. doi: 10.1136/annrheumdis-2019-215048.

[4]Zemer D. Muscle pains in familial Mediterranean fever. Harefuah 1984; 106: 232-233.

[5]Majeed HA. Differential diagnosis of fever of unknown origin in children. Curr Opin Rheumatol 2000; 12: 439-444.

[6]Piram M, Frenkel J, Gattorno M et al. EUROFEVER and EUROTRAPS networks. A preliminary score for the assessment of disease activity in hereditary recurrent fevers: results from the AIDAI (Auto-Inflammatory Diseases Activity Index) Consensus Conference. Ann Rheum Dis. 2011 Feb;70(2):309-14. doi: 10.1136/ard.2010.132613.

[7]Salaffi F, Carotti M, Gutierrez M, Di Carlo M, De Angelis R. (2015) Patient Acceptable Symptom State in Self-Report Questionnaires and Composite Clinical Disease Index for Assessing Rheumatoid Arthritis Activity: Identification of Cut-Off Points for Routine Care. Biomed Res Int. 2015:930756. doi: 10.1155/2015/930756.

Table 1.

Comparison of clinical and laboratory parameters between patients with /without myalgia attacks

Patients with myalgia attackPatients without myalgia attackp valueAge (years)36,33 ±10, 6837,9±11, 48>0,05Sex (female/male)78/43138/87>0,05Follow-up time (years)16,117,6>0,05Dominant attack(number)Peritonitis4255>0,05Arthritis11390,012Pleuritis1310>0,05Only fever47>0,05AIDAI score (mean, 0-175)127,4080,68<0,05VAS score for pain (median score, during attack. 0-10)85<0,05Colchicine resistance (number ofpatients)69250,003Colchicine-resistant29840,002Colchicine-sensitivePASS status (number)Need additional treatment4160,016Satisfied from treatment34740,010Work/study day loss (number)4860,003

Acknowledgements

All study population signed informed consent for both participation and publication. Local Ethical Committee of the university approved the study.

Disclosure of Interests

None declared

AB1088 COVID-19 VACCINATION OF SPONDYLOARTHRITIS PATIENTS RECEIVING BIOLOGICAL THERAPY: REAL-LIFE DATA

Background

Considering the concerns regarding COVID-19 vaccine safety among patients with rheumatic diseases due to a lack of data, an urgent need for studies evaluating safety profiles of vaccines emerged.

Objectives

Vaccination against the coronavirus disease-2019 (COVID-19) started in March 2021 in the group using biological therapy in our country. In this study, post-vaccine real-life data of patients with spondyloarthritis (SpA) followed up with biological therapy were analyzed.

Methods

Adult patients diagnosed with SpA who were followed up under biological therapy and vaccinated by CoronaVac inactive SARS-CoV-2 orBNT162b2 messenger RNA (mRNA) COVID-19 (Pfizer-BioNTech) vaccine were included in our observational, multicenter, prospective study.

Results

A total of 287 patients (58.2% male; mean age: 47) were included in the study. 202 (%70,4) of patients were being followed up with the diagnosis of AS, 40 (%13,9) of them with PsA, 32 (%11,1) of them with nr-axSpA, 11 (%3,8) of them with enteropathic arthritis, and 2 (%0,7) of them with uSpA. The most common comorbidities were found to be HT (n:65; 22.6%) and DM (n:38; 13.2%). While 221 (77%) of the patients were receiving biological therapy alone, 27 (9.4%) patients were using methotrexate, 25 (8.7%) patients were using sulfasalazine, and 12 (4.2%) patients were using leflunomide. The median duration of biological therapy was 40 weeks (19-75 IQR). The most commonly used treatment was infliximab (26.8%), adalimumab (23.3%) was the second (Table 1).

It was determined that 207 (72.1%) of the patients preferred inactivated virus vaccine, while 80 (27.9%) preferred mRNA vaccine. When the time between the biological treatment and the day of vaccination is examined, detected median time between biological treatment and the first dose of vaccination is 11.5 days (5-19 IQR), between the first dose of vaccination and biological treatment is 14 days (7-21 IQR), between treatment and the second dose of vaccine is 14 days (5-23.5 IQR), and between the second dose of vaccine and the next biological treatment is 12.5 days (7-15 IQR). While 25 (8.7%) of the patients had COVID-19 infection before vaccination, 7 (2.4%) patients were found to have COVID-19 after vaccination (p<0.001). While two of the patients who had COVID-19 infection in the pre-vaccination period required hospitalization, none of the patients who had COVID-19 in the post-vaccination period required hospitalization.

The rate of patients who developed side effects after the first dose of the vaccine was 20.6%. The side effects seen, respectively, were detected as pain-redness at the injection site (16%), fatigue (11.8%), headache (8.4%), muscle-joint pain (7.3%) and fever (5.6%). The rate of patients reporting side effects after the second dose of the vaccine was 17.1%. The incidence of side effects after mRNA vaccine was found to be statistically significant compared to inactivated virus vaccine in terms of both doses (p=0.011, p<0.001). Major side effects such as myocarditis, anaphylaxis-angioedema, myocardial infarction, and thrombosis were not observed in any of the patients included in the study. There was no evidence of disease activation in the median follow-up of 209 days (145-280 IQR) after vaccination.

Conclusion

During the follow-up of the patients during the study, no major vaccine-related side effects, post-vaccine disease activation and the need for treatment change were not detected. In order to more accurately evaluate the efficacy of the vaccination program in the patient population using biologic agents, larger-scale studies including unvaccinated individuals are needed.

References

[1]Sattui SE, Liew JW, Kennedy K, et al. Early experience of COVID-19 vaccination in adults with systemic rheumatic diseases: results from the COVID-19 global rheumatology alliance vaccine survey. RMD Open. 2021;7(3):e001814.

[2]Shenoy P, Ahmed S, Paul A, et al. Inactivated vaccines may not provide adequate protection in immunosuppressed patients with rheumatic diseases. Ann Rheum Dis. 2021. doi:10.1136/annrheumdi s-2021-221496

Disclosure of Interests

None declared

Individual differences in the experience of meta-mood and internalizing psychopathology

Introduction

Emotional competencies such as attention to emotion and emotional clarity have been extensively studied in the literature. Depending on the context, their role shows different patterns of association with emotion regulation and psychopathological states.

Objectives

In the current study, we aim to understand when and how attention to emotion and emotional clarity are related to the co-occurrence of anxiety and depression.

Methods

Data were collected on attention to emotion, emotional clarity, anxiety, and depression. A sample of 258 adolescents aged 12 to 18 years (M = 14.6, SD = 1.7, 54.5% girls) was examined to investigate the moderating role of attention to emotion and emotional clarity on the relationship between anxiety and depression after controlling for age, gender, and socioeconomic status.

Results

showed that high levels of attention to emotion and low levels of emotional clarity were associated with increased risk for anxiety and depression. Balanced levels of attention to emotion and emotional clarity were also associated with increased risk for anxiety and depression. However, low levels of attention to emotion and high levels of emotional clarity showed no statistically significant association with the occurrence of anxiety and depression.

Conclusions

Overall, this positive imbalance of low attention to emotion and high emotional clarity appears to be the most favorable emotional states for coping with internalizing problems, suggesting less harmful effects of attention to emotion.

Disclosure

No significant relationships.

AB1301 DETERMINING THE RELATIONSHIP BETWEEN SERUM INTERLEUKIN 33 LEVELS AND CLINICAL FEATURES OF THE DISEASE IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER

Background

Familial Mediterranean Fever (FMF) is an autoinflammatory disease characterized by recurrent fever, serositis, arthritis and erysipelas-like erythema caused by mutations over activating caspase-1. As Interleukin (IL)-1 beta, IL-33 is a nuclear cytokine from IL-1 family which is activated by caspase-1. IL-33 is known to take part in pathogenesis of several rheumatic diseases.

Objectives

The aim of this research is determining the relationship between serum IL-33 levels and clinical features of the disease in patients with FMF disease.

Methods

The research involved 54 FMF patients and 29 healthy volunteers. Serum IL-33 levels were evaluated in both patients and healthy individuals, and its relationship between clinical and laboratory features of FMF.

Results

28 out of 54 patients (%51.8) had favorable response to colchicine while 26 patients (%48.2) had colchicine resistant disease. FMF patients had lower IL-33 levels compared to healthy control group (p= 0.06). There were no difference between colchicine responsive and resistant patients (p=0.12) and no association was found between clinical features and serum IL-33 levels. Additionally, IL-33 did not correlated with C-reactive protein and disease activity assessed by autoinflammatory disease activity index.

Conclusion

No association was found between serum IL-33 levels and FMF disease features and laboratory findings. This may be due to the small size of our patient group, the involvement of IL-33 in tissue homeostasis as well as inflammation, and the use of higher doses of colchicine in the resistant disease group than in the remission group. Additional research is needed to determine IL-33’s role in FMF pathogenesis and its relationship with clinical and laboratory features.

References

[1]Ozdogan, H. and S. Ugurlu, Familial Mediterranean Fever. Presse Med, 2019. 48(1 Pt 2): p. e61-e76.

[2]Cayrol, C. and J.P. Girard, Interleukin-33 (IL-33): A nuclear cytokine from the IL-1 family. Immunol Rev, 2018. 281(1): p. 154-168.

[3]Duan, L., et al., The role of IL-33 in rheumatic diseases. Clin Dev Immunol, 2013. 2013: p. 924363.

Acknowledgements

None of the authors obtained any financial support.

Disclosure of Interests

None declared

AB1302 EVALUATING THE CLINICAL UTILITY OF PATIENT ACCEPTABLE SYMPTOM STATE IN PATIENTS WITH FAMILIAL MEDITERRANEAN FEVER

Background

Familial Mediterranean Fever (FMF) is an autoinflammatory disease characterized by recurrent attacks of fever, serositis, arthritis and erysipelas-like erythema. Patient acceptable symptom state (PASS) is a disease evaluation method to assess disease activity with a simple question especially in rheumatic diseases.

Objectives

We aimed to investigate clinical utility of PASS in FMF patients.

Methods

The research involved 54 FMF patients. Patient acceptable symptom state was applied to all patients in the study. The answers to PASS were compared with the patients clinical and laboratory features.

Results

28 out of 54 patients (51.8%) were colchicine responsive whereas, 26 patients (48.2%) had colchicine resistant disease. The number of patients who answered yes to PASS (I’m happy with my current disease condition) was 32 (59%), while answered no (I need further treatment options) was 22 (41%). Considering the disease severity assessed with International severity scoring FMF (ISSF) of those who answered yes, 22 (68%) patients had mild disease, 10 patients had moderate (32%) disease, and there was no patient with severe disease in this group. Among those who answered no, 3 (14%) had mild disease, 14 (63%) had moderate disease, and 5 (23%) had severe disease (p <0.001). When the CRP levels of the patients were compared, the median CRP value of those who answered yes was found to be 4.45 mg/L, and the median value of CRP for those who answered no was 11.25 mg/L (p= 0.04).

Sensitivity and specificity of PASS for detecting patients in remission was 78% and 61% respectively. Moreover, PASS had a positive and negative predictive value of %68 and %72 respectively, for determining patients in remission. If cut off level of CRP was chosen as 6.5 mg/L for answering “yes” to PASS, sensitivity of test has been found to be 62.5% while the specificity is 59.1%. On the other hand, if cut off level of CRP is selected as 9.35 mg/L; sensitivity and specificity of the test was found as 75% and 72.7% respectively (p=0.045).

Conclusion

Patient acceptable symptom state is found beneficial in evulation these patients simply and swiftly especially in terms of distinguishing severe FMF disease. In FMF, laboratory remission is as important as clinical remission, therefore, PASS by alone, is not sufficient for making treatment decisions and should be supported by inflammatory markers.

References

[1]Ozdogan, H. and S. Ugurlu, Familial Mediterranean Fever. Presse Med, 2019. 48(1 Pt 2): p. e61-e76.

[2]Lubrano, E., et al., Assessment of the Patient Acceptable Symptom State (PASS) in psoriatic arthritis: association with disease activity and quality of life indices. RMD Open, 2020. 6(1).

[3]Salaffi, F., et al., Patient Acceptable Symptom State in Self-Report Questionnaires and Composite Clinical Disease Index for Assessing Rheumatoid Arthritis Activity: Identification of Cut-Off Points for Routine Care. Biomed Res Int, 2015. 2015: p. 930756.

[4]Maksymowych, W.P., et al., Evaluation and validation of the patient acceptable symptom state (PASS) in patients with ankylosing spondylitis. Arthritis Rheum, 2007. 57(1): p. 133-9.

Acknowledgements

None of authors obtained any financial support

Disclosure of Interests

None declared

POS1328 DO IL-1 ANTAGONISTS DEFINITELY PROTECT FROM THE DEVELOPMENT OF NEW DAMAGE: A SINGLE-CENTER STUDY

Background

Ongoing inflammatory episodes of familial Mediterranean fever (FMF) disease can cause damage in nearly all organ systems. Colchicine and interleukin1β blocking agents are successfully used to control the disease activity [1]. Although the effect of IL-1 blockers are known for controlling disease activity and amyloidosis [2], it is unclear whether they prevent organ damage

Objectives

In our study, we assessed the organ damage in patients with FMF treated with colchicine and IL-1 antagonists (IL-1A). It was evaluated whether new damage occurred after IL-1 antagonist treatment.

Methods

A total of 111 patients fulfilling Tel-Hashomer criteria and treated with IL-1A due to colchicine resistance were included in the study. All patients were also treated with colchicine with a maximum-tolerable dose. Patients were grouped according to their recent damage status (no damage, pre-existing damage, and damage developed under IL-1A treatment). The degree of damage was determined using Autoinflammatory Disease Damage Index (ADDI) and modified form of ADDI (mADDI) [3, 4].

Results

44 patients (42,3%) had damage according to the modified ADDI (mADDI) index; three patients experienced new damage under IL-1 antagonist treatment while four patients showed progression of damage and mADDI score.

In patients with a positive mADDI score, the most common damage was amyloidosis (n=28, 63%), the second most frequent was musculoskeletal findings (N=14, 31%), and the third was infertility (N=2, 0,04%). The most common domains of FMF-related damage with IL-1 antagonist treatment were musculoskeletal (n=4), renal (n=2) and reproductive system (n=2)

Conclusion

Our study was the first study to evaluate the progression of damage in patients with FMF and treated- with IL-1 antagonists. Although it is known that IL-1A is effective in colchicine-resistant patients, physicians should be aware that damage can still develop under IL-1A treatment.

References

[1]Chae JJ, Aksentijevich I, Kastner DL. Advances in the understanding of familial Mediterranean fever and possibilities for targeted therapy. Br J Haematol 2009; 146:467–78.

[2]Ozcakar ZB, Ozdel S, Yilmaz S, Kurt-Sukur ED, Ekim M et al. Anti-IL-1 treatment in familial Mediterranean fever and related amyloidosis. Clinical Rheumatology 2016; 35 (2): 441- 446. doi: 10.1007/s10067-014-2772-2

[3]Ter Haar NM, Annink KV, Al-Mayouf SM et al.: Development of the autoinflammatory disease damage index (ADDI). Ann Rheum Dis 2017; 76: 821-30

[4]Babaoglu H, Armagan B, Bodakci E, Satis H, Atas N, Sari A, Yasar Bilge NS, Bilici Salman R, Yardimci GK, Avanoglu Guler A, Karadeniz H, Kilic L, Ozturk MA, Goker B, Haznedaroglu S, Kalyoncu U, Kasifoglu T, Tufan A. Factors associated with damage in patients with familial Mediterranean fever. Clin Exp Rheumatol. 2020 Sep-Oct;38 Suppl 127(5):42-48.

Table 1.

Comparison of clinical and laboratory parameters between groups according to damage

No damageNew damageAny damageP valueAge (years)48,456,467,50,002Sex (K/E)34/332/525/19NSFollow-up time (years)4043560,33Dominant attack typePeritonitis(63,7%)NAArthritis(34,1%)NSPersistent inflammation33,642,344,30,05AIDAI score394048NSMutationsM694V/M694V26214NSM694V/any44438M694V/M680I314M680I/any119

•SAIDAI: Auto-Inflammatory Diseases Activity Index

Acknowledgements

All participants were confirmed for both participation and publication. Local Ethical Committee approved the study

Disclosure of Interests

None declared

Systematic assessment of complications after laparoscopic colorectal surgery for advanced colorectal cancer: A retrospective study using Clavien–Dindo classification, 5-year experience

AimThe presence and frequency of surgical complications indicate the quality of the surgery performed. However, a standard classification system should specify, describe, and compare complications. Clavien Dindo classification is an easily applicable classification in the evaluation of complications. Our study aimed to reveal the severity of complications and the factors affecting them by using the Clavien Dindo classification in patients undergoing laparoscopic colorectal surgery.MethodsBetween January 2015 and December 2020, we retrospectively collected the laparoscopic colorectal surgery complications using Clavien Dindo grading in patients in our colorectal surgery unit in the database. The outcome variables studied were age, gender, BMI, ASA score, postoperative length of hospital stay, operation procedure, cancer size, postoperative mortality.ResultsThere were 53 males and 17 female patients, with a mean age of 56,9±13,4.(19-81). Seventy patients, 32 (45%), had at least one postoperative complication. About complications; 58.6% were rated as Clavien I, 22.9% as Clavien II, 8.6% as Clavien IIIa, 4.3% as Clavien IIIb, 2.9% as Clavien IVa, and 2.9% as Clavien V. There was no Clavien grade IVb complication in any of the patients. Length of hospital stays was significantly higher in patients with had major complex surgery and had higher scores. Clavien Dindo classification was positively statistically significantly related to the day of hospitalization in male and female sex (p<0.001 for all). In addition, positively significantly related to Clavien Dindo classation and tumor diameter in the female sex (p=0.014) detected.ConclusionsIn laparoscopic colorectal surgery, the Clavien-Dindo classification can be easily applied and used safely to determine complication rates. The reason for this statistical difference that we detected in our study and that occurs in women may be due to anatomical differences or the surgeon’s experience.

Is there a threshold for red cell distribution width to predict malignancy in breast masses?

Background

Red cell distribution width (RDW) has been shown to have predictive properties in different diseases as well as solid cancers.

Aim

We aimed to investigate the discriminative properties of RDW in benign and malignant breast lesions.

Subjects and Methods

In a retrospective cohort study the files of patients who underwent surgery for fibroadenomas (Group A) and breast cancer with axillary lymph node metastasis (Group B) were reviewed. The pathology reports and laboratory parameters and demographics of the patients were recorded for comparison. The patients were later excluded if they had an hemoglobin level below 12 mg/dl and the outliers were removed for a comparison. Seventy-six patients in the fibroadenoma group and 62 patients in the breast malignancy group were compared for the RDW levels to predict the presence of malignancy. Receiver operating characteristic curves were plotted for RDW and a threshold for prediction of malignancy was calculated.

Results

The difference in RDW levels between group A and group B was found to be significant, 13,10% (IQR 12.60 -13.70) versus 13,80% (IQR 13.10-14.40) respectively, P = 0,00. The area under the curve was 0.71 (95% confidence interval 0.62 to 0.79), P = 0,00. For the threshold of 13,75 the positive predictive value was 67.35 (95% CI 55.72 to 77.17) and negative predictive value was 67.42 (95% CI 60.76% to 73.44).

Conclusion

The RDW levels, after adjusted for anemia, were found to have a positive prediction for malignancy in more than two thirds of the patients for the level of 13.75%.

Rat Model Investigation on the Role of Biomarkers in Hepatic Ischemia-Reperfusion Injury

OBJECTIVES

Liver function is affected by ischemiareperfusion. Ischemia-reperfusion injury to the liver often follows hepatobiliary surgery. Here, we investigated biomarkers of liver ischemia-reperfusion injury using an animal model.

MATERIALS AND METHODS

For this study, 24 male Sprague Dawley rats (146-188 g) were divided into 4 groups: group A was the control group, group B was the partial hepatic ischemia-reperfusion group, group C was the total hepatic ischemia-reperfusion group, and group D was the intermittent total hepatic ischemiareperfusion group. Laboratory liver function levels were measured before ischemia, after ischemia, and after reperfusion. We used liver and renal biopsies for histopathological examination at the end of the study.

RESULTS

After clamping and reperfusion, alanine aminotransferase and cystatin C levels in groups B, C, and D were significantly higher than levels in group A. In group B, after clamping, neutrophil gelatinaseassociated lipocalin levels were higher than in groups A and D, with significantly higher level than in group D after reperfusion. Neutrophil gelatinase-associated lipocalin levels decreased significantly in groups B, C, and D after reperfusion. There was significantly greater hepatic damage in groups B, C, and D compared with group A but no significant differences in renal injury scores among the groups. There was a significant positive correlation between hepatic damage and renal injury. With regard to histopathological examination versus laboratory results, a statistically significant positive correlation was shown between grade of hepatic damage and serum alanine aminotransferase and cystatin C levels. Similarly, there was a positive correlation between renal damage score and alanine aminotransferase level.

CONCLUSIONS

In our animal model, alanine amino - transferase and cystatin C levels tended to increase with ischemia-reperfusion injury levels but neutrophil gelatinase-associated lipocalin decreased during reperfusion. In liver ischemia, we suggest that neutrophil gelatinase-associated lipocalin may be an important biomarker for distinguishing the reperfusion phase.

Preoperative appendix diameter obtained by computerized tomography scanning predicts conversion from laparoscopic to open appendectomy

Background

Open appendectomy (OA) has been the gold standard for a long time. Laparoscopic appendectomy (LA) has gained wide acceptance and popularity, outdoing open approach. Yet, conversion may be required when laparoscopic approach fails.

Aims

To predict conversion from laparoscopic appendectomy to open appendectomy sing Oreo-ratio radiological appendices diameter.

Materials and Methods

This is a retrospective cohort study conducted on 320 (included) patients who underwent appendectomy between January 2018 and August 2018 in the General Surgery departmentof Haseki Training and Research Hospital, Istanbul, Turkey. Appendiceal diameter obtained during preoperative radiological screening was evaluated about its relationship to conversion from LA to OA. Age, sex, inflammatory serum parameters and pathology reports were also investigated.

Results

A total of 269 (84%) cases were started LA and 17 (6,3%) laparoscopic cases were converted to open. The appendix diameter, the grade of inflammation (perforated or gangrenous), age, and c-reactive protein (CRP) were found to have significant importance in conversion, P = 0.003, P = 0.000, P = 0.042, and P = 0.018, respectively. When a cutoff of 50 years was chosen for age, the odds ratio (OR) was 3. For the appendiceal diameter of 14 mm, the OR was 3.0286.

Conclusion

Preoperative evaluation of appendix diameter is a quick and useful method for a surgeon to distinguish cases with risk of conversion in the emergency department. The other risk factors associated with conversion of LA to OA are grade of inflammation, age and CRP levels.

Is there any association between jugular venous reflux and nonpulsatile subjective tinnitus? A preliminary study of four-dimensional magnetic resonance angiography

Objective

To demonstrate whether there is an association between jugular venous reflux and nonpulsatile subjective tinnitus (NST) using real-time four-dimensional magnetic resonance imaging (MRI) angiography.

Materials and Methods

Patients with unilateral NST who underwent contrast-enhanced MRI with a special protocol were included in the study. Thick slab dynamic maximum intensity projection images were obtained including interleaved stochastic trajectories (TWIST)-MRI examination. All patients were requested to perform Valsalva maneuver during the sequence. Jugular venous reflux grading was performed as follows: absence of reflux or if reflux does not reach the base of the skull: grade 0; if reflux reaches the jugular bulb, but no intracranial contrast is observed: grade 1; and if reflux extends into the intracranial cortical veins and/or the cavernous sinus above the jugular bulb: Grade 2.

Results

A total number of 30 patients, 23 male and 7 female, were included in the study. Jugular venous reflux was not identified (Grade 0) in 20 patients. Grade 1 reflux was determined in 7 cases and Grade 2 reflux was observed in 3 cases. Notably, only patients with Grade 2 reflux described worsening of their tinnitus symptoms during the examination and their daily activities as well.

Conclusions

NST might also be associated with hemodynamic problems of the venous system and the MRI protocol starting with TWIST accompanied with Valsalva maneuver is not well-known, yet seems to be a feasible and beneficial method to detect potential jugular venous reflux in NST patients.

Open mesh and laparoscopic total extraperitoneal inguinal hernia repair under spinal and general anesthesia

INTRODUCTION

Mesh placement is the main standard in repair of inguinal hernia, and laparoscopic repair is the standard of care via spinal, epidural, or combined anesthesia. Here, we compared open and laparoscopic total extraperitoneal (TEP) repairs under general (GA) and spinal anesthesia (SA).

METHODS

Inguinal hernia patients (n=440) were analyzed retrospectively. There were four groups: Group 1 was TEP under GA (TEP-GA) (n=111); Group 2 was open mesh repair (OM) under SA (n=116) (OM-SA); Group 3 was open mesh repair under GA (n=117) (OM-GA); Group four was TEP under SA (n=96) (TEP-SA). The age, body mass index, duration of operation, hospital stay, postoperative Visual Analog Scale scores, recurrence, postoperative pain, urinary retention, headache, and patient satisfaction were all recorded.

RESULTS

There was no significant difference in terms of hypotension, vomiting, seroma and scrotal edema, recurrence, and wound infection incidence between the groups. However, the operation duration, hospital stay period, headache, urinary retention, postoperative Visual Analog Scale scores, chronic pain, and patient satisfaction showed significant differences between groups.

CONCLUSION

Laparoscopic TEP hernia repair is a safe and effective method along with its advantages of shorter hospital stay, less recurrence, less postoperative pain, higher patient satisfaction, and similar postoperative complication rates. SA has the disadvantage of higher incidence of headache and urinary retention compared to GA.

In the Experimental Model of Acute Mesenteric Ischemia, The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.

The Effect of Sterilization Methods of Endoscopic Instruments on the Body: A Study on Rat Model

PURPOSE

Laparoscopy is widely used in many surgical areas for diagnosis and treatment. The need for sterilization of reusable instruments is an important issue. Ensuring patient safety, preventing infection, and protecting the functionality of the instruments are the most important points to be considered. We aimed to investigate two sterilization methods and their effects generated by their distribution into intra-abdominal tissues during insufflation.

MATERIALS AND METHODS

21 rats were used in the study. The Control Group (Group 1) received anesthesia for 1 hour; Group 2 (Glutaraldehyde (GA)-Pneumoperitoneum Group) received anesthesia for 1 hour; Group 3 (Ethylene Oxide (EO)-Pneumoperitoneum Group) received anesthesia for 1 hour. After 24 hours, the animals were sacrificed, and the kidneys and omentum of the animals were analyzed in a histopathological manner. Blood samples were analyzed at preoperative 24th hour and at postoperative 24th hour.

RESULTS

There was a statistically significant difference in omentum, endothelium, and glomerular scores between the groups (p < 0.001 for all groups). Endothelial and glomerular scores were different at a statistically significant level in the EO and GA groups compared to the Control Group. The total score was higher at a statistically significant level in the EO and GA groups compared to the Control Group (p < 0.001 for both groups).

CONCLUSION

It was determined in our study that sterilization methods such as EO and GA cause damage in intra-abdominal tissues. In the light of these results, we consider that the most ideal laparoscopic surgery set is the single-use laparoscopy set. However, this does not seem possible especially in developing countries in practice.

Combined spinal-epidural anesthesia in laparoscopic appendectomy: a prospective feasibility study

Purpose

Laparoscopic appendectomy (LA) is routinely performed under general, not regional anesthesia. This study assessed the feasibility, efficacy, and side effects of combined spinal-epidural anesthesia (CSEA) in LA.

Methods

Thirty-three American Society of Anesthesiologist (ASA) physical status classification grade I patients underwent LA under CSEA. CSEA was performed using the needle-through-needle technique at the L₃–L₄ interspace. Preoperative and postoperative adverse events related to CSEA, patient satisfaction, and postoperative pain levels were recorded.

Results

LA under CSEA was performed successfully in 33 patients (84.6%). Peroperatively, right shoulder pain was observed in 8 patients (24.1%), abdominal discomfort in 6 (18.2%), anxiety in 5 (15.2%), hypotension in 2 (6.1%) and nausea-vomiting in 1 (3%). In the first 24 hours after LA, headache, urinary retention, right shoulder pain, and postoperative nausea/vomiting (PONV) occurred in 18.1%, 12.1%, 9.1%, and 0% of patients, respectively. In the first 6 hours postoperation, no patients had operation-site pain that required analgesic treatment. Thirty-one patients (94%) evaluated their satisfaction with the procedure as good or moderate.

Conclusion

CSEA is an efficient and suitable anesthesia technique in LA for ASA physical status classification grade I healthy patients. CSEA is associated with good postoperative pain control and the absence of PONV and intubation-associated complications.

Laparoscopic cholecystectomy under spinal-epidural anesthesia vs. general anaesthesia: a prospective randomised study

Purpose

Laparoscopic cholecystectomy (LC) is usually performed under the general anesthesia (GA). Aim of the study is to investigate the availability, safety and side effects of combined spinal/epidural anesthesia (CSEA) and comparison it with GA for LC.

Methods

Forty-nine patients who have a LC plan were included into the study. The patients were randomly divided into GA (n = 25) and CSEA (n = 24) groups. Intraoperative and postoperative adverse events, postoperative pain levels were compared between groups.

Results

Anesthesia procedures and surgeries for all patients were successfully completed. After the organization of pneumoperitoneum in CSEA group, 3 patients suffered from shoulder pain (12.5%) and 4 patients suffered from abdominal discomfort (16.6%). All these complaints were recovered with IV fentanyl administration. Only 1 patient developed hypotension which is recovered with fluid replacement and no need to use vasopressor treatment. Postoperative shoulder pain was significantly less observed in CSEA group (25% vs. 60%). Incidence of postoperative nausea and vomiting (PONV) was less observed in CSEA group but not statistically significant (4.2% vs. 20%). In the group of CSEA, 3 patients suffered from urinary retention (12.5%) and 2 patients suffered from spinal headache (8.3%). All postoperative pain parameters except 6th hour, were less observed in CSEA group, less VAS scores and less need to analgesic treatment in CSEA group comparing with GA group.

Conclusion

CSEA can be used safely for laparoscopic cholecystectomies. Less postoperative surgical field pain, shoulder pain and PONV are the advantages of CSEA compared to GA.

Do Turkish gynecologists have sufficient knowledge on the basic principles of electrosurgery?

AIM

The aim of the current study was to evaluate the level of the basic knowledge of the Turkish gynecologists regarding electrosurgery.

MATERIALS AND METHODS

A survey was undertaken to evaluate the level of basic knowledge and attitudes regarding electrosurgery use among gynecology specialists and residents. The questionnaire used comprised of two parts: a) questions evaluating the participants' professional experience, whether they had received formal electrosurgery training, and their course of action concerning the use and safety precautions of the electrosurgery unit, and b) questions designed to evaluate the knowledge level of the participants on the basic electrosurgical principles.

RESULTS

One hundred seventy-three gynecologists were included in the study and their mean knowledge score was 49.1 %. No difference was detected between the mean scores of specialists and residents. The mean score of participants who had read articles/papers on electrosurgery was significantly higher compared with uninformed participants (p =0.001). The mean score of participants who had previously attended electrosurgery training seminars was significantly higher compared with participants who had not attended seminars (p =0.013).

CONCLUSION

Gynecologists in Turkey do not have sufficient basic knowledge regarding the reliable and efficient use of electrosurgery. HIPPOKRATIA 2017, 21(1): 8-12.

A case of rudimentary horn pregnancy diagnosed after failed attempts at pregnancy termination

We report a case of rudimentary horn pregnancy at 12 weeks gestation with fetal demise misdiagnosed ultrasonographically as an intrauterine pregnancy in a private clinic. The patient was referred to a tertiary care hospital after failed attempts at terminating her pregnancy. A definitive diagnosis was made with ultrasonography and magnetic resonance imaging (MRI) before uterine rupture ensued. Excision of the rudimentary horn and the ipsilateral fallopian tube was carried out by laparotomy. Failure to terminate pregnancy after several attempts should alert the physician about the possibility of a uterine anomaly and a pelvic MRI scan may help in the diagnosis of a suspected rudimentary horn pregnancy.

Is there any effect of pneumoperitoneum pressure on coagulation and fibrinolysis during laparoscopic cholecystectomy?

Background

Laparoscopic cholecystectomies (LC) are generally performed in a 12 mmHg-pressured pneumoperitoneum in a slight sitting position. Considerable thromboembolism risk arises in this operation due to pneumoperitoneum, operation position and risk factors of patients. We aim to investigate the effect of pneumoperitoneum pressure on coagulation and fibrinolysis under general anesthesia.

Material and Methods

Fifty American Society of Anesthesiologist (ASA) I–III patients who underwent elective LC without thromboprophlaxis were enrolled in this prospective study. The patients were randomly divided into two groups according to the pneumoperitoneum pressure during LC: the 10 mmHg group (n = 25) and the 14 mmHg group. Prothrombin time (PT), thrombin time (TT), International Normalized Ratio (INR), activated partial thromboplastin time (aPTT) and blood levels of d-dimer and fibrinogen were measured preoperatively (pre), one hour (post1) and 24 h (post24) after the surgery. Moreover, alanine amino transferase, aspartate amino transferase and lactate dehydrogenase were measured before and after the surgery. These parameters were compared between and within the groups.

Results

PT, TT, aPTT, INR, and D-dimer and fibrinogen levels significantly increased after the surgery in both of the groups. D-dimer level was significantly higher in 14-mmHg group at post24.

Conclusion

Both the 10-mmHg and 14-mmHg pressure of pneumoperitoneum may lead to affect coagulation tests and fibrinogen and D-dimer levels without any occurrence of deep vein thrombosis, but 14-mmHg pressure of pneumoperitoneum has a greater effect on D-dimer. However, lower pneumoperitoneum pressure may be useful for the prevention of deep vein thrombosis.

Two-port laparoscopic appendectomy assisted with needle grasper comparison with conventional laparoscopic appendectomy

Purpose

The 2-port laparoscopic appendectomy technique (TLA) is between the conventional 3-port and single-port laparoscopic appendectomy surgeries. We compared postoperative pain and cosmetic results after TLA with conventional laparoscopic appendectomy (CLA) by a 3-port device.

Methods

Patients undergoing TLA were matched with patients undergoing CLA between February 2015 and November 2015 at the same institution. Thirty-two patients underwent TLA with a needle grasper. The appendix was secured by a percutaneous organ-holding device (needle grasper), then removed through a puncture at McBurney's point. Another 38 patients underwent CLA. Patient demographics, operative details, and postoperative outcomes were collected and evaluated.

Results

One patient in the TLA group developed a wound infection and 1 patient in the CLA group developed a postoperative intra-abdominal abscess and 3 wound infections. There was no significant difference between the groups when comparing the length of hospital stay, time until oral intake, and other complications. The pain score in the first 12 hours after surgery was significanly higher in CLA group than the TLA group (P < 0.001). Operative time was significantly shorter in the CLA group compared to the TLA group (P < 0.001).

Conclusion

TLA using a needle grasper was associated with a significantly lower pain score 12 hours after surgery, better cosmetic results, and lower cost, than the CLA 3-port procedure because of the fewer number of ports.

Adverse perinatal outcomes of adolescent pregnancies in one center in Istanbul, Turkey

PURPOSE

The objective of this study was to evaluate fetal and perinatal outcomes of pregnancies of adolescents and compare them with adult pregnancies.

MATERIALS AND METHODS

This retrospective case-control study was carried out at Bakirkoy Maternity and Children's Diseases Education and Research Hospital in Istanbul, Turkey. It enrolled 2,491 pregnancies who delivered between 2005-2010, of which 998 were adolescent pregnancies and 1,493 were adults as controls.

RESULTS

The mean age of the adolescent group was 17.10 years and in the control group the mean age was found to be 26.73 years. Intermarriage, vaginal delivery, preterm rupture of membranes, preterm birth, and preeclampsia were significantly higher in adolescent pregnancies than the control group. Gestational diabetes was more common with increasing age. There was no statistically meaningful difference between the groups in terms of intrauterine growth restriction (IUGR), low birth weight, anemia, 5-minute APGAR score, and intrauterine fetal demise.

CONCLUSIONS

Young maternal age is a risk factor for preterm birth, preterm rupture of membranes, and preeclampsia. According to this study, adolescent pregnancies are more risky and more likely to have adverse fetal outcomes.

Evaluation of tularaemia courses: a multicentre study from Turkey

In this multicentre study, which is the largest case series ever reported, we aimed to describe the features of tularaemia to provide detailed information. We retrospectively included 1034 patients from 41 medical centres. Before the definite diagnosis of tularaemia, tonsillitis (n = 653, 63%) and/or pharyngitis (n = 146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (n = 832, 85.3%), glandular (n = 136, 13.1%) and oculoglandular (n = 105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (n = 599, 58%), submandibular (n = 401, 39%), and periauricular (n = 55, 5%). Ultrasound imaging showed hyperechoic and hypoechoic patterns (59% and 25%, respectively). Granulomatous inflammation was the most frequent histological finding (56%). The patients were previously given antibiotics for 1176 episodes, mostly with β-lactam/β-lactamase inhibitors (n = 793, 76%). Antituberculosis medications were provided in seven (2%) cases. The patients were given rational antibiotics for tularaemia after the start of symptoms, with a mean of 26.8 ± 37.5 days. Treatment failure was considered to have occurred in 495 patients (48%). The most frequent reasons for failure were the production of suppuration in the lymph nodes after the start of treatment (n = 426, 86.1%), the formation of new lymphadenomegalies under treatment (n = 146, 29.5%), and persisting complaints despite 2 weeks of treatment (n = 77, 15.6%). Fine-needle aspiration was performed in 521 patients (50%) as the most frequent drainage method. In conclusion, tularaemia is a long-lasting but curable disease in this part of the world. However, the treatment strategy still needs optimization.

A new parameter in the diagnosis of vascular erectile dysfunction with penile Doppler ultrasound: cavernous artery ondulation index

AIM

Our aim is to introduce the cavernous artery ondulation index (CA-OI) as a new parameter that could be accepted as an indirect indicator of vascular hemodynamics and also gives us information about the efficiency of erection.

PATIENTS AND METHODS

A total of 27 patients with erectile dysfunction were evaluated with penile Doppler ultrasonography (PDUS). After injection of papaverine intracavernously, arterial diameter and peak-systolic and end-diastolic velocities were measured. For measuring at a standart time, five minutes after injection, bilateral cavernosal arteries were examined and gray scale and color Doppler US images through the long axis were recorded at the mentioned phases. Cavernosal artery ondulation index (CA-OI) showing the amount of ondulation was calculated for each subject using these images.

RESULTS

In 9 of total 27 patients, erection could not pass the tumescence phase with 3 flaccid phases, while the remaining 18 had full erection. Mean CA-OI values were measured as 2.51±0.37 mm, 3.15±0.38 mm, and 2.68±0.09 mm in normal, arterial insufficiency and venous insufficiency groups, respectively.

CONCLUSIONS

It is possible to differentiate the arterial insufficiency by using the cut-off value of CA-OI ≥ 2.5 values as a criteria.

Virtual bronchoscopy using FDG-PET/CT images for the evaluation of lung cancer

PURPOSE

We aimed to put forward the contribution of virtual bronchoscopy in the determination and diagnosis of tracheobronchial system pathologies. We compared the data obtained from PET/CT and virtual bronchoscopy (VB) with the fiberoptic bronchoscopy (FOB) data of the cases with a diagnosis or pre-diagnosis of lung tumor.

MATERIALS AND METHODS

A total of 261 (male=238, female=23) lung cancer cases with a mean age of 53±7.3 years (range =35-77 years), who had undergone FOB and had bronchoalveolar lavage and/or biopsy results, were included in this multicenter, prospective study conducted between 2006 and 2008. FOB data confirmed with cytohistopathology were considered as the gold standard. Five cases that had peripheral lesions, with negative cytopathological results were excluded from the study. Positron emission tomography images were fused with 16/slice multi-detector computed tomography system images (Discovery ST PET/16 slice CT fusion system HPOWER 60; General Electric Medical Systems, Milwaukee, WI, USA). Thereafter, all of the cases were evaluated with virtual bronchoscopy, using a special multidisplay workstation with multiplanar reformatting (MPR) and minimum intensity projection (MINIP) to see the fused images simultaneously. The data obtained with both virtual bronchoscopy (PET/CT VB) and FOB in different centers were recorded, and the evaluation and comparison of these data were done by an independent researcher. The sensitivity, specificity, and positive and negative predictive values of making an accurate diagnosis and defining concomitant pathologies by both methods, were calculated.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy values of VB and PET/CT-VB in determining the segment involved by malignancy were as follows, 91%, 83%, 94%, 77%, and 89%, and 95%, 97%, 99%, 87%, and 96%, respectively.

CONCLUSIONS

The sensitivity of PET/CT-VB in determining the involved tracheobronchial segment(s) in malignancy and concomitant pathologies in cases with lung tumor was remarkably higher than that with CT-VB. Therefore, PET/CT-VB is recommended to be included in routine lung cancer examinations since it provides similar outcomes to that of FOB+cytohistopathological examination.

Nodule or pseudonodule? Differentiation in Hashimoto's thyroiditis with sonoelastography

Fine needle aspiration biopsy (FNAB) is the gold standard for the diagnosis of lymphoma in Hashimoto's thyroiditis and is able to differentiate between benign, inflammatory or malignant nodules, classifying them as either true nodules or pseudonodules. This technique is, however, invasive. The present study aimed to differentiate pseudonodules from true nodules by sonoelastography, a non-invasive technique, in 54 patients with Hashimoto's thyroiditis. The accuracy of sonoelastography to differentiate between true or pseudonodules was compared with the gold standard FNAB and with grey scale ultrasonography. The nodules were categorized into three groups: non-demarcated hypoechogenic, demarcated hyperecho genic, and demarcated hypoechogenic. Sono elastography findings were concordant with the cytopathological results and demonstrated that sono elastography was able to detect true thyroid nodules often misdiagnosed by conventional grey scale ultrasonography. Sonoelastography was found to have increased sensitivity for true nodule diagnosis compared with conventional grey scale ultrasonography and may eliminate unnecessary FNABs being carried out.

Evaluation of the gastro-oesophageal junction: defining the incompetent cardio-oeosophageal angle non-invasively with ultrasound and computerized tomography

This study aimed to demonstrate the presence of gastro-oesophageal reflux disease (GORD) non-invasively using ultrasound (US) and computerized tomography (CT). Intra-abdominal oesophageal length (IAOL) and cardio-oesophageal angle (COA) were measured by US in 25 patients with known reflux and in 25 healthy subjects (control group). CT images of 42 patients with reflux disease and 44 controls were reviewed retrospectively, and IAOL and COA were measured on curved multiplanar format images. Using a cut-off value for IAOL of 20.5 mm, the sensitivity to detect GORD with US was 96% and the specificity was 80% and, with CT, the sensitivity was 95% and the specificity was 78%. A cut-off value of 138.5° for COA yielded sensitivity and specificity values for GORD detection of 76% and 72% with US and 83% and 80% with CT, respectively. In conclusion, with equivocal diagnostic findings, IAOL and COA are useful parameters that can be determined non-invasively by US or CT and may aid diagnosis and treatment choices for patients with suspected GORD.

Indirect measurement of the temporomandibular joint disc elasticity with magnetic resonance imaging

OBJECTIVES

The radiological evaluation of the temporomandibular joint (TMJ) consists of demonstrating the morphological features of the disc and the condyle in closed and open mouth positions using MRI. We aimed to determine elasticity of the disc by measuring the amount of elongation during mouth opening.

METHODS

The study population included 49 patients. Coronal T(1) and multiplane oblique T(2) weighted gradient recalled echo sequences were acquired in open and closed mouth positions. Biconcave TMJ disc lengths were measured on sagittal oblique images in both positions. Elongation ratio (ER) was calculated for each patient. According to the findings, TMJs are classified into subgroups: normal (N), dislocated with reduction (DWR), pure DWR (p-DWR), DWR with additional findings (DWR-a) and dislocated without reduction (DWOR). Statistical analysis was performed using the χ(2) test and receiver operating characteristic analysis.

RESULTS

Out of 98 discs, 22 of them were evaluated as N, 60 as DWR (28 p-DWR, 32 DWR-a) and 16 as DWOR. There was no significant difference among the disc lengths in three subgroups at the closed mouth position (P = 0.15), whereas there was significant difference in the open mouth position (P = 0.0001). There was significant difference among subgroups as far as ER is concerned (P < 0.05).

CONCLUSIONS

ER is a strong indicator of elasticity. Compared with the N group, elasticity of the disc was not significantly different in the p-DWR group but the disc elasticity was very degraded in DWR-a and in DWOR. A negative conversion or one smaller than 1.4 mm means a compromised disc, although sometimes it will possess normal anatomical configurations or signal characteristics.

Early Diagnosis of Oral Cancer

Survival rates for oral cancer are very poor, at approximately 50% overall, and have not improved markedly in recent decades despite advances in therapeutic interventions. Detecting oral cancer at an early stage is believed to be the most effective means of reducing rates of death, morbidity and disfigurement from this disease. Tobacco and alcohol consumption and pre-malign lesions are the most common aetiological factors. The proportion of patients presenting with oral cancer at an advanced stage is troubling. Early diagnosis is the most effective way of reducing the individual burden of the disease, decreasing morbidity and mortality and improving quality of life. For early diagnosis, healthcare providers should perform oral cancer examinations as part of their patient care regime, and need to be knowledgeable about early signs of oral carcinoma. Oral cancer awareness among the public should also be improved.

Bullying among nurses and its effects

BACKGROUND

The victims of bullying are subjected to being terrorized, annoyed, excluded, belittled, deprived of resources, isolated and prevented from claiming rights. The victims of bullying have decreased job satisfaction, work performance, motivation and productivity. Bullying also negatively affects victims' social relationships inside and outside the institution.

OBJECTIVES

This study was conducted as a cross-sectional and descriptive study for the purpose of assessing the workplace, bullying of nurses in Turkey and the effects it has on nursing practices.

METHOD

The sample was composed of 286 nurses, and all of the respondents were female. The research instrument was a questionnaire in five parts. The first section included the participants' demographic information; the other variables were measured in four categories: psychologically violent behaviours, workload, organizational effects and depression.

FINDINGS

Thirty-seven per cent of the nurses participating in the research had never or almost never encountered workplace bullying behaviour in the last 12 months, 21% of the nurses had been exposed to these behaviours. There were no differences between position and educational level in workplace bullying. Workplace bullying leads to depression, lowered work motivation, decreased ability to concentrate, poor productivity, lack of commitment to work, and poor relationships with patients, managers and colleagues.

CONCLUSION

Workplace bullying is a measurable problem that negatively affects the psychology and performance of the nurses in this study.

Do contraceptive choices of Turkish married adolescents differ from those of older women?

OBJECTIVE

To compare contraceptive choices of Turkish married adolescents to those of women of reproductive age and perimenopausal women.

METHODS

Demographic variables, fertility goals and contraceptive choices of adolescents (Group A, n = 95) were compared with those of women of reproductive age (Group B, n = 5224) and perimenopausal women (Group C, n = 2208).

RESULTS

All women in the study group were married and had delivered at least once. A past history of voluntary terminations of pregnancy (TOPs) was reported often, although significantly less so by adolescents (43.1%) than by women belonging to the other two groups (66.5 and 77.4%, respectively). The percentage of women who applied no contraception was significantly higher in Group A (p < 0.05). The rate of use of withdrawal, oral contraceptives and intrauterine devices did not differ significantly between the three groups. The percentage of women who were indecisive about future pregnancy or wanted to have more children was greatest in Group A (87.4, 46.9 and 25.7%, respectively; p < 0.05).

CONCLUSION

The distribution of contraceptive methods used was similar among the three age groups, but the absence of contraception was most frequent in the adolescent group. The adolescents we assessed, being married and having delivered at least once, are a highly selected group and not representative of adolescents in general. Nevertheless, their contraceptive choices did not differ from those of older women. The incidence of TOPs among them was quite high. Minimization of the frequent neglect of application of contraceptive measures by adolescents requires improvement of family planning services for this age group.

Lower extremity venous pathology mimicking deep vein thrombosis: 2 case reports

We report two cases of lower extremity venous pathology mimicking deep vein thrombosis (DVT). The first case was a 20-year-old male with swelling in the left leg. Colour Doppler ultrasound (CDUS) demonstrated a continuous flow pattern, and computed tomography (CT) revealed compression of the dilated left common iliac vein by the right common iliac artery (May-Thurner syndrome). This dilatation of the vein was caused by overload due to the drainage of the gluteal arteriovenous malformations into this vein. The second case was a 55-year-old female with swelling and pain of the left leg persisting for a year following an operation of a herniated lumbar disk. She was diagnosed as DVT and treated accordingly. Control CDUS performed in our department demonstrated a left iliac arteriovenous fistula and a pulsatile flow pattern in the left femoral vein. CT also confirmed this arteriovenous fistula. We suggest that if not all criteria for the diagnosis of DVT are fullfilled by CDUS, another imaging modality such as multidetector CT should be used.

Dacryolith: two case reports

Dacryolith is a concretion within the nasolacrimal system. Dacryoliths may cause intermittent epiphora without inflammation, or recurrent dacryocystitis may develop. In this report, we present two patients with dacryoliths. The first patient had presented with a complaint of swelling and epiphora and had been told that she had lacrimal canal obstruction. This patient was unaware of the cause of obliteration and was asymptomatic. The second patient complained of headache, eye swelling and inflammation; dacryolith was diagnosed by clinical examination and dacryocystography. Dacryoliths were detected on the panoramic radiographs as small, rounded, radiopaque calcifications located in the inner aspect of the medial wall of the orbit. The image of dacryoliths must be differentiated from radiographic artefacts and foreign objects, and it is important to recognize dacryoliths on panoramic radiographs and to refer the patients for medical care, if necessary.

Incidence of canine impaction and transmigration in a patient population

In this study, 4500 consecutive panoramic radiographs were prospectively reviewed. The incidence of canine impaction was found to be 3.58% and the incidence of canine transmigration was 0.31%. There were six maxillary and eight mandibular transmigrant canines. The incidence of impacted canine teeth and transmigration of maxillary and mandibular canines may be more frequent than was previously thought, at least in some populations.

Multiple impacted permanent and deciduous teeth

Multiple impacted teeth may be related to syndromes and metabolic disorders. In some cases, however, impaction of multiple teeth is not accompanied by a fixed complex of symptoms. A 55-year-old woman attended our clinic, as she was not comfortable with her prosthetic appliances because of erupted teeth. Panoramic and occlusal radiographs revealed 13 impacted teeth (12 permanent and 1 deciduous) in the maxilla and 15 impacted teeth (11 permanent and 4 deciduous) in the mandible. In total the patient had 28 impacted teeth. In our case, medical and family history and extraoral examination were not suggestive of any syndrome or metabolic disorder. In conclusion, radiographic examination may reveal multiple impactions in clinical absence of teeth. Lack of eruptive force and rotation of tooth buds may cause multiple impactions and additional examinations may be necessary to exclude systemic and metabolic conditions.