Effectiveness of multimedia-assisted training on inhaler usage technique, which is the optimum technique?

OBJECTIVE

In this study, we aimed to investigate the most appropriate education method for patients to use their inhaler devices with the proper technique.

PATIENTS AND METHODS

The study had a cross-sectional, multicenter design. 525 consecutive patients who had never used an inhaler therapy before were included in the study. Seven different types of inhalers were evaluated. 75 patients were included for each device type. For each device type, 25 patients were trained by their own physicians who personally demonstrated the use of the device [verbal education with physical demonstration (VEWPD)], 25 were given multimedia-assisted training (MAT), and 25 received both types of training together (first VEWPD followed by MAT). After the patients were trained, inhaler medications were used under the supervision of a physician. Correct use of the inhaler devices and perceptions of convenience were scored.

RESULTS

For Ellipta inhaler device and Levered Diskus inhaler device, the proportion of patients using their devices properly was significantly higher in patients who were instructed with both of the methods together compared to other education groups (p = 0.011, p = 0.015). The effects of different types of training on learning in Sanohaler, Diskus inhaler, and Pressurized metered dose inhaler devices were the same.

CONCLUSIONS

We could not come to a conclusion that multimedia training was more beneficial than other training. As an unexpected result, in almost all of the devices, patients who received multimedia training in combination with verbal training did not develop better learning despite being shown the use of the device twice (except Ellipta inhaler, and Levered Diskus inhaler device).

Fournier's Gangrene: Our Five-Year Series and the Role of Vacuum-Assisted Closure in the Treatment

Background

Fournier's Gangrene (FG) is the necrotizing fasciitis of the perineal region.

Aims

To compare the effectiveness of debridement alone and debridement with vacuum-assisted closure in the treatment of Fournier's gangrene.

Methods

Twenty-two patients operated for FG were analyzed retrospectively. Debridement-only and debridement + VAC treatment groups were compared in terms of age, gender, predisposing factors, comorbid diseases, intensive care unit and hospital stay durations, laboratory results, septic shock, treatment methods, Fournier' gangrene severity index (FGSI) and mortality.

Results

The M/F ratio was 13/9. There were 10 and 12 patients in debridement-only and debridement + VAC groups, respectively. Ten patients (45.5%) were admitted to intensive care unit, 8 (36.4%) needed colostomy and 7 (31.9%) developed septic shock, respectively. The mortality rate was 27.3%. There was no significant difference in terms of age, gender, laboratory parameters, number of debridement, length of stay in intensive care unit and hospital, shock duration, and mortality (P > 0.05). The FGSI scores also did not show any difference between the groups which showed that the severity of the disease in both groups are similar.

Conclusion

The VAC treatment was found not to provide a statistically significant benefit on mortality. Early and adequate debridement and antibiotic are still the most important factors in the treatment of FG and to reduce mortality.

Effect of Genetic Factors on the Etiopathogenesis of Thrombosed Hemorrhoidal Disease

OBJECTIVE

The aim of this study is to investigate whether genetic factors known to increase thrombosis risk play a role in the etiopathogenesis of thrombosed hemorrhoidal disease. Methods: Genomic DNA from patients with thrombosed hemorrhoidal disease was analyzed for the presence of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T, and methylenetetrahydrofolate reductase A1298C mutations. Results: No significant differences were found in the allele frequencies of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T, and methylenetetrahydrofolate reductase A1298C mutations between patients with thrombosed hemorrhoidal disease and controls (p 0.05). Moreover, there were no significant differences in the genotype (heterozygous and homozygous mutations) of factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase C677T and A1298C mutations between patients with thrombosed hemorrhoidal disease and controls (p 0.05). Conclusions: Our findings indicate that mutations associated with venous thromboembolism do not play a role in the etiopathogenesis of thrombosed hemorrhoidal disease; however, several environmental, mechanical, and hemodynamic factors may contribute to the etiopathogenesis of hemorrhoidal disease.

Long-Term Effect of Sublingual and Subcutaneous Immunotherapy in Dust Mite-Allergic Children With Asthma/Rhinitis: A 3-Year Prospective Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Specific allergen immunotherapy is the only treatment modality that might change the natural course of allergic diseases in childhood. We sought to prospectively compare the long-term clinical and immunological effects of sublingual (SLIT) and subcutaneous (SCIT) immunotherapy compared with pharmacotherapy alone.

METHODS

In this single-center, prospective randomized controlled trial, 48 children with mild persistent asthma with/without rhinitis, monosensitized to house dust mites (HDMs) were followed for 3 years. At baseline and years 1 and 3 of follow-up, patients were evaluated and compared for total rhinitis (TRSS) and asthma (TASS) symptom scores, total symptom scores (TSS), total medication scores (TMS), safety profiles, skin-nasal-bronchial reactivity, and immunological parameters.

RESULTS

A significant reduction was observed in TASS for both HDM-SCIT and HDM-SLIT at year 3 of treatment compared with baseline and controls (P<.05 for both), with significant improvement in rhinitis symptoms for both groups compared with controls (P=.01 for both). TSS decreased significantly in both HDM-SCIT and HDM-SLIT at year 3 compared with baseline (P=.007 and P=.04, respectively) and controls (P<.01 for both). A significant reduction in TMS was observed in HDM-SCIT and HDM-SLIT compared with baseline and controls (P=.01 in all cases), with a reduction in skin reactivity to HDM (P<.05). Finally, a significant increase in allergen specific IgG4 was observed in the SCIT group at year 3 compared with baseline, the SLIT group, and controls (P<.001 in all cases).

CONCLUSIONS

HDM-sensitized asthmatic children treated for at least 3 years with either SCIT or SLIT showed sustained clinical improvement.

Role of human neutrophil gelatinase associated lipocalin (NGAL) and Matrix Metalloproteinase-9 (MMP-9) overexpression in neoplastic colon polyps

To explore the role of Human neutrophil gelatinase associated lipocalin (NGAL) and Matrix Metalloproteinase-9 (MMP-9) overexpression in neoplastic polyps and might used as a marker to separate those from non-noeplastic polyps. The study was performed on total 65 cases, 40% (n = 26) of them females and 60% (n = 39) of them males, in Haydarpasa Numune Education and Research Hospital between March 2012 and June 2012. The assessment of immunostained sections was performed by a random principle by one experinced pathologists to the clinico-pathological data. NGAL expression was based on the presence of cytoplasmic and membranous staining. The NGAL intensities of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). The NGAL prevalences of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). The NGAL ID scores of the cases show highly statistically significantly difference according to the pathological results (p < 0.01). We could hypothesize that NGAL and MMP-9 overexpression in neoplastic polyps might be used as a marker to separate those from non-noeplastic polyps. However, in this study, we determined that NGAL overexpression could not distinguish dysplasia from adenocancer. Finally, we suggest NGAL and MMP-9 as an immunohistochemical marker for colonic dysplasia. To determine dysplasia in early steps of colorectal adenoma-carcinoma sequence, it could help to determine new targets in preventive cancer therapy for colorectal cancer. We suggest development of standards for study method, introduction to routine practice by investigating in future studies including many patients.

Use of stapling devices for safe cholecystectomy in acute cholecystitis

Many techniques are described for the ligation of a difficult cystic duct (CD). The aim of this study is to assess the effectiveness and safety of stapling of a difficult CD in acute cholecystitis using Endo-GIA. From January 2008 to June 2012, 1441 patients with cholelithiasis underwent laparoscopic cholecystectomy (LC) at the Department of General Surgery, Haydarpasa Numune Education and Research Hospital. Of these, 19 (0.62%) were identified as having a difficult CD and were ligated using an Endo-GIA stapler. All patients were successfully treated with a laparoscopic approach. The length of hospital stay was 3.4 days. There were umbilical wound infections in 4 patients (21%). The length of follow-up ranged from 1.0 to 50.4 months. In conclusion, Endo-GIA is a safe and easy treatment method for patients with a dilated and difficult CD. The cystic artery should be isolated and ligated if possible before firing the Endo-GIA stapler. If isolation and stapling are not possible, fibrin sealant can be applied to avoid bleeding. The vascular Endo-GIA can be applied in a large CD, but for acute cholecystitis with an edematous CD, the Endo-GIA roticulator 4.8 or 3.5 stapler is preferred.

Long-term effects of forgotten biliary stents: a case series and literature review

There are many studies about the biliary stents, however there is a little information about the long-term stayed forgotten biliary stents except a few case reports. We have reported the results of a number of cases with biliary stents that were forgotten or omitted by the patient and the endoscopist. During February 2010 to May 2013, five patients were referred to the general surgery clinic of Haydarpasa Numune Training and Research Hospital, Istanbul Turkey. Past history and medical documents submitted by the patient did not indicate a replacement of the biliary stent in 3 patients. Two patients knew that they had biliary stents. We also conducted a literature review via the PubMed and Google Scholar databases of English language studies published until March 2014 on forgotten biliary stent. There were 3 men and 2 women ranging in age from 22 to 68 years (mean age 41.6 years). Patients presented with pain in the upper abdomen, jaundice, fever, abnormal liver function tests or dilatation of the biliary tract alone or in combination. Patients' demographic findings are presented in Table 1. A review of three cases reported in the English medical literature also discussed. The mean duration of the patency of the stent is about 12 months. The biliary stenting is performed either with plastic or metal stents, studies recommending their replacement after 3-6 months. Patients with long stayed forgotten biliary stents are inevitably treated with surgical intervention. We recommend for all endoscopic retrograde cholangiopancreatography units provide a stent registry system that the stents placed for various therapeutic procedures are not forgotten both by the patient as well as the physician. There should be a deadline for biliary stents in the registry system for each patient.

An unusual presentation of perforated appendicitis in epigastric region

INTRODUCTION

Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation.

PRESENTATION OF CASE

A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver.

DISCUSSION

While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality.

CONCLUSION

Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.

A modified Rendezvous ERCP technique in duodenal diverticulum

AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs.

METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast.

RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%.

CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.

Treatment of ampullary neuroendocrine tumor by endoscopic snare papillectomy

Patient: Female, 45

Final Diagnosis: Neuroendocrine tumor

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Surgical approach to splenic hydatid cyst: single center experience

The benefits and risks of surgery for splenic hydatid cyst (SHC) remain controversial. We aimed to share our experience about a surgical approach for SHC. Sixteen consecutive patients with SHC disease who underwent open splenectomy at our hospital between January 2006 and July 2012 were retrospectively evaluated. Data on the patients' demographic features, clinical findings, radiological and serological diagnostic methods, and surgical and medicinal treatment options were collected and used to generate descriptive profiles of diagnosis, treatment course, and outcome. The patient population was composed of 6 females and 10 males, with an age range of 18 to 79 years (mean age: 47.0 ± 18.0). Radiological examinations detected hydatid cysts in spleen alone (n = 7) or both spleen and liver (n = 9). Preoperative serological testing identified 13 of the patients as IHA positive. All except 1 patient received a 10- to 21-day preoperative course of albendazole therapy and all patients received vaccination 1 week prior to surgery. Seven patients underwent splenectomy. The remaining patients underwent splenectomy with partial cystectomy and omentopexy (n = 6), partial cystectomy and unroofing (n = 1), pericystectomy (n = 1), or pericystectomy with partial nephrectomy (n = 1). All except one patient received a 10- to 45-day postoperative course of albendazole. No patients developed serious complications or signs of recurrence during the follow-up. The clinical profile of SHC disease at our hospital includes diagnosis by radiological methods, splenectomy treatment by simple or concomitant procedures according to the patient's symptoms, cyst size, number and localization, and compression of adjacent organs, and adjunct vaccination to decrease risk of postoperative septic complications. This profile is associated with low risk of complications and high therapeutic efficacy.