The Effect of Modified Early Warning Score (MEWS) and Nursing Guide Application on Postoperative Patient Outcomes: A Randomized Controlled Study

PURPOSE

The aim of this study is to determine the effect of nursing guide application (NGA) on patient outcomes in patients followed up according to the modified early warning score (MEWS) in the postoperative period.

DESIGN

A randomized controlled clinical trial.

METHODS

The sample of the study consisted of 252 patients who underwent surgical intervention under general anesthesia in a university hospital between July 29, 2022, and October 31, 2022.

FINDINGS

Results showed that the development of complications was less in the study group (SG) compared to the control group (CG) during anesthesia (P = .027), in the postanesthesia care unit (PACU) (P = .017), and in the clinic (P = .001). It was found that the duration of stay in PACU in the CG was significantly shorter than in the study group (P < .001), and as the duration of stay in PACU in CG decreased, the MEWS increased (r = -0.201, P = .024). We found that there were fewer patients transferred to the intensive care unit (ICU) after PACU (P = .007), the MEWS was lower, and the number of nursing interventions applied to patients was higher (P < .05).

CONCLUSIONS

In patients followed up according to MEWS, NGA had a positive effect on preventing the development of complications and shortening the intervention time for complications, decreasing ICU admission, decreasing MEWS and increasing the number of nursing interventions. Based on the results, it may be recommended to use MEWS+NGA in the early postoperative period as it positively affects patient outcomes.

Determination of SARS-CoV-2 IgG antibody levels in hematology-oncology patients after COVID-19 vaccination

OBJECTIVE

Cancer patients are among the high-risk groups where COVID-19 infection tends to be severe and can lead to increased mortality. Therefore, they are included in the priority groups for COVID-19 vaccination. This study aimed to compare the levels of SARS-CoV-2 immunoglobulin G (IgG) antibodies following two different COVID-19 vaccinations between hematology-oncology patients and healthcare personnel and to identify factors associated with these antibody levels.

PATIENTS AND METHODS

A prospective study was conducted with 91 hematology-oncology patients (cancer group) and 75 healthcare personnel (control group) from January 2020 to June 2023. The cancer and control groups comprised adults who had received a booster dose, with either a single dose of BNT162b2 or two doses of CoronaVac™ spaced one month apart, following their primary vaccination with two doses of either CoronaVac™ or BNT162b2. Four weeks after the administration of the booster dose, levels of SARS-CoV-2 IgG antibodies were assessed using an ELISA kit. Antibody levels above 50 AU/mL were accepted as signifying seropositivity.

RESULTS

The median SARS-CoV-2 IgG antibody level was lower in the cancer group compared to the control group (4,509 vs. 7,268, p = 0.004), while the rate of seroconversion was similar between the groups (97.8% vs. 100%, p = 0.564). In the cancer group, no association was found between SARS-CoV-2 IgG antibody levels and age, sex, comorbidity, type of malignancy, stage and duration, or type of vaccine.

CONCLUSIONS

In cancer patients, the seroconversion positivity rate was about 98%. However, antibody responses were still lower compared to the control group. No difference was detected in antibody levels among cancer patients based on the type of vaccine.

[Plan A blocks]

With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing number of new block techniques also led to confusion. Therefore, seven basic regional anesthesia techniques that are effective in most of the surgeries have been listed as 'Plan A Blocks.' The purpose of this review is to introduce the basic sono-anatomy and indications of Plan A blocks.

Comparison of haemodynamic response to tracheal intubation with two different videolaryngoscopes: A randomized clinical trial

BACKGROUND

Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI.

METHODS

Fifty ASA II...III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24...hours following extubation.

RESULTS

The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p...=...0.024; p...=...0.012; p...=...0.030; p...=...0.009, respectively). In group analyses, T1...T2, T2...T3 and T1...T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1...T3) (p...=...0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p...<...0.001), but the duration of intubation and total intubation were similar (p...=...0.36; p...=...0.79).

CONCLUSIONS

Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.

The modified pectoral nerve block versus bi-level erector spinae plane block for postoperative analgesia after radical mastectomy surgery: A prospective, randomized, controlled trial

Background

Regional anesthesia techniques constitute an important part of successful analgesia strategies, and in the perioperative care of breast surgery patients. The advent of ultrasound-guided regional anesthesia led to the development of fascial plane blocks. The abundance of blocks available for postoperative analgesia in breast surgery has increased the accessibility of regional anesthesia but has also created the dilemma of choice. This study compared the analgesic efficacy of ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane block (ESPB) in patients undergoing modified radical mastectomy (MRM).

Method

Seventy women were enrolled for the study. After exclusion, 67 female patients undergoing MRM were finally analyzed. Ultrasound-guided PECS block and ESPB were performed with 30 ml 0.25% bupivacaine in this prospective, double-blind, randomized control trial. Postoperative morphine and pain scores were compared between the groups.

Results

Postoperative total morphine consumption in the first 24 h was significantly higher in the PECS group (P = 0.000). The ESPB group exhibited significantly reduced morphine consumptions at all postoperative time points. Numeric rating scale scores were lower in the ESPB group at postoperative 6, 12, and 24 h at rest and when coughing.

Conclusions

Ultrasound guided bi-level ESPB provided better postoperative analgesia compared to PECS block after radical mastectomy surgery.

A randomized comparison between ultrasound-guided costoclavicular and infraclavicular block for upper extremity surgery

Background/aim

This study compared ultrasound guided costoclavicular (CC) and lateral sagittal infraclavicular (LS) brachial plexus block in patients undergoing upper extremity surgery.

Materials and methods

A total of 80 patients undergoing upper extremity surgery were randomly classified into two groups: Group CC (costoclavicular (n = 40)) and Group LS (lateral sagittal infraclavicular (n = 40)). Both groups received a 25 mL containing a mixture of 1% lidocaine and 0.25% bupivacaine. A blinded observer recorded the block onset time and decided which patients who were admitted to the operation room needed general anesthesia or rescue block or without any iv. narcotics for the surgical procedure.

Results

The sensorimotor onset time was found to be faster in the CC group [(15.95 2.97) min] compared to the LS group [(17.72 4.15)min]. There was a statistically significant difference between two groups in terms of sensorimotor onset time (p = 0.031). There was no difference between two groups in terms of the block performance times and post-block motor block dissolution times.

Conclusion

The CC approach provides faster onset of sensorimotor blockade than LS approach when the 4 major terminal nerves of the brachial plexus were evaluated.

A Pseudocoarctation of the Aorta With a Left Subclavian Artery Aneurysm, A Case Report and A Review of the Literature

Here we present a 47-year-old male diagnosed with a pseudocoarctation of the aorta and a funnel-like subclavian artery aneurysm with a large orifice and severe aortic valve insufficiency. The patient underwent a two-stage repair for both pathologies. After an aortic valve replacement, postcardiotomy pericardial effusion occurred and was medically managed. Six months later, the patient underwent a distal arcus aorta and subclavian artery replacement with a left posterolateral thoracotomy as the second stage. Due to the strict adhesions, pulmonary veins were not cannulated and an extracorporeal bypass between the pulmonary artery and femoral artery was used for distal body perfusion. The coincidence of subclavian aneurysms and a pseudocoarctation of the aorta is rare and a literature review was performed to identify treatment options for this pathology.

Comparison of the lateral sagittal and costoclavicular approaches for ultrasound-guided infraclavicular block in pediatric patients: a prospective randomized study

BACKGROUND

The lateral sagittal brachial plexus block is the most used method for pediatric upper extremity surgery, whereas the applications of costoclavicular brachial plexus block are limited. This study aimed to compare the lateral sagittal and costoclavicular approaches for the ultrasound-guided infraclavicular block in pediatric patients.

METHODS

Sixty pediatric patients aged 5-15 years undergoing hand or forearm surgery were randomly assigned to two groups. Group LS (n = 30) received ultrasound-guided lateral sagittal block, and Group CC (n = 30) received ultrasound-guided costoclavicular block. The block performing time, needling time, imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores were evaluated.

RESULTS

The needling time (82.90 ± 28.17 seconds vs. 64.77 ± 28.11 seconds respectively, p = 0.004) and total block performance time (109.53 ± 29.75 seconds vs. 89.70 ± 29.98 seconds respectively, p = 0.005) were significantly longer in Group LS than in Group CC. However, there was no significant difference between the groups in imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores (p > 0.05).

CONCLUSIONS

Costoclavicular and lateral sagittal brachial plexus blocks resulted in similar anesthetics effects. Moreover, the costoclavicular method can be a better alternative to lateral sagittal as it has a shorter block performance time.

Deciding between moral priorities and COVID-19 avoiding behaviors: A moral foundations vignette study

Novel moral norms peculiar to the COVID-19 pandemic have resulted in tension between maintaining one's preexisting moral priorities (e.g., loyalty to one's family and human freedoms) and avoiding contraction of the COVID-19 disease and SARS COVID-2 virus. By drawing on moral foundations theory, the current study questioned how the COVID-19 pandemic (or health threat salience in general) affects moral decision making. With two consecutive pilot tests on three different samples (ns ≈ 40), we prepared our own sets of moral foundation vignettes which were contextualized on three levels of health threats: the COVID-19 threat, the non-COVID-19 health threat, and no threat. We compared the wrongness ratings of those transgressions in the main study (N = 396, M _age = 22.47). The results showed that the acceptability of violations increased as the disease threat contextually increased, and the fairness, care, and purity foundations emerged as the most relevant moral concerns in the face of the disease threat. Additionally, participants' general binding moral foundation scores consistently predicted their evaluations of binding morality vignettes independent of the degree of the health threat. However, as the disease threat increased in the scenarios, pre-existing individuating morality scores lost their predictive power for care violations but not for fairness violations. The current findings imply the importance of contextual factors in moral decision making. Accordingly, we conclude that people make implicit cost-benefit analysis in arriving at a moral decision in health threatening contexts.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12144-021-01941-y.

Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations.

MATERIALS AND METHODS

This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I.ÇôII, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups.

RESULTS

There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6^th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011).

DISCUSSION

In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Erector spinae block for postoperative pain management in lumbar disc hernia repair

PURPOSE

Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries.

METHODS

Fifty-four ASA I-II patients aged 18-65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery.

RESULTS

A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p < 0.05 for each timepoint). Total morphine consumption at 24 h after surgery decreased by 57% compared to that of the control group (11.3 ± 9.5 mg in the ESP group and 27 ± 16.7 mg in the control group). NRS scores were similar between the two groups.

CONCLUSION

This study showed that ESP block provided effective analgesia in patients who underwent lumbar disc herniation surgery.

CLINICAL TRIALS REGISTRY

NCT03744689.

General Anesthesia Practices During the COVID-19 Pandemic in Turkey: A Cohort Study With a National Survey

Introduction This study aimed to examine the anesthesia practices applied to the cases during the pandemic, to analyze the rate of the precautions taken in emergency/elective operations in non-COVID patients, what precautions were taken, what resources the clinics had, and the patient management in the perioperative period by organizing a survey among anesthesiologist in Turkey. Methods After obtaining approval from the Turkish Ministry of Health (2020-05-04T09_30_03) and the local ethics committee (GOKAEK-2020/10.09), a survey consisting of 21 questions was formed over the online survey inquiry (surveymonkey.com). The survey was conducted in Turkish. Results The survey aimed at reaching the anesthesiologists, who were Turkish Anesthesiology and Reanimation Society (TARD) members, by e-mail, and it was seen that 120 people out of approximately 2700 members who had received our e-mail participated in the survey. After the first case was reported in our country, it was understood that 62.1% of the participants stopped accepting elective cases in their institutions. The anesthesia method preferred in this period was general anesthesia by 47.6%, regional anesthesia by 52.1%, and sedation by 0.3%. The arrival time of coronavirus disease COVID-19 tests (PCR and/or rapid diagnostic kits showing antibodies) to the hospital was questioned; seven people (5.83%) stated that tests were not performed at their hospitals. It was observed that tests arrived and were applied at the hospitals of the remaining participants in an average of 2.7 ± 1.6 weeks. It was determined that 59.32% of the participants avoided positive pressure ventilation after induction, 5.98% of the intubation on the patients were performed by anesthesia technicians, 66.67% by anesthesiologists, 25.64% by senior resident doctors with at least two years of experience, and 1.71% by junior anesthesia assistants with less than two years of experience. The use of personal protective equipment (PPE) is applied by 95% of the participants. 22.69% of the participants stated that they preferred to use supraglottic airway (SGA) devices during this period. While 45.06% of the participants stated that they provided oxygen support to the patient with the mask belonging to the circuit after extubation, 14.8% preferred the nasal cannula, and 33.1% used an oxygen mask. Our results showed that 90% of additional precautions were taken in our country's clinics, and 95% of PPE was used. Also, the use of video laryngoscope (VL) was 75% in this period. Finally, it was found that 50.85% of the patients were taken to the recovery unit after being extubated, and 49.15% were sent directly to the service. Conclusion We can reveal that each clinic made arrangements according to its own conditions. We think that plans should be made to standardize clinical facilities and algorithms throughout the country. Apart from technological and financial facilities, we believe that the continuity of the training organized by national and international associations should be ensured so that anesthesiologists' knowledge, skills, and experience who manage this process can remain at the highest level.

Regional Anesthesia Practices in Turkey During the COVID-19 Pandemic

Introduction

The aim of the survey was to investigate the changes, methods, and preferences in regional anesthesia (RA) applications during the COVID-19 pandemic in Turkey.

Methods

The questionnaire prepared on surveymonkey.com was sent to anesthesiology and reanimation specialists by e-mail.

Results

A total of 126 physicians participated in the study. Forty-two point sixty-two percent (42.62%) of the participants reported an increase in RA practices in their clinical anesthesia applications, whereas 57.38% did not state any change. Neuraxial anesthesia was determined to be the most preferred RA application, with a rate of 74%. The distribution of peripheral nerve blocks (PNBs) showed that upper extremity blocks were used at a rate of 64.9%, lower extremity blocks at 30.38%, and trunk blocks at 15%. Investigation of neurostimulator (NS) and/or ultrasound (US) use with PNB showed that 44% of the participants used only US while 50% used both US and NS.

Conclusion

Neuraxial blocks play an important role in RA applications. PNB comprise one-quarter of RA applications during the pandemic. The importance of ultrasound has gradually increased in RA applications worldwide, as well as in Turkey, during the pandemic.

[Surgical anesthesia using ultrasound-guided penile nerve block for adult hemophilia patient]

Ultrasound-Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who had hemophilia A and was undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for the DPNB. Surgery was completed under block without complication. Twenty-four hours of the analgesia was provided following surgery.

People respond with different moral emotions to violations in different relational models: A cross-cultural comparison

Consonant with a functional view of moral emotions, we argue that morality is best analyzed within relationships rather than in individuals, and use Fiske's (1992) theory of relational models (RMs: communal sharing [CS], authority ranking [AR], equality matching [EM], and market pricing [MP]) to predict that violations in different RMs will arouse different intensities of other-blaming emotions (anger, contempt and disgust) in both observers and victims, together with different intensities of self-blaming emotions (shame and guilt) in perpetrators, and to predict that these patterns of emotion will show similarity across both individuals and cultures. Three studies, using vignettes portraying moral violations in all RMs in different experimental designs, supported these expectations, while also producing some unexpected results. The intensity of shame and guilt varied markedly across RMs, but with little difference between the two emotions. The intensity of all 3 other-blaming emotions also varied across RMs. Anger was the most intense emotional response to violation in all RMs, whereas disgust and contempt were stronger in CS than in other RMs. Disgust and shame were linked more strongly in CS than in other RMs, and anger and guilt were more strongly linked than other emotion pairs in EM. Moral emotions in RMs involving hierarchy (AR and MP) differed widely depending on the perpetrator's dominant or subordinate status. Both Turkish (TR) and English-speaking (EN) samples showed similar patterns of all moral emotions across RMs. Understanding the functions of moral emotions in relationships using relational models can help to clarify multiple aspects of moral psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Postoperative Analgesic Efficacy of the Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Decompression Surgery: A Randomized Controlled Study

BACKGROUND

Spinal surgery is a procedure that causes intense and severe pain in the postoperative period. Erector spinae plane (ESP) block can target the dorsal-ventral rami of thoracolumbar nerves, but its effect on lumbar surgery is unclear. The aim of this study was to investigate the effect of the ESP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery.

METHODS

Sixty patients undergoing open lumbar decompression surgery were randomly assigned to 2 groups. The ESP Group (n = 30) received ultrasound-guided bilateral ESP block with 0.25% bupivacaine 20 mL. In the Control Group (n = 30), no intervention was performed. Postoperative analgesia was performed intravenously twice a day with 400 mg ibuprofen and patient-controlled analgesia with tramadol. Postoperative visual analogue scale scores, opioid consumption, rescue analgesia, and opioid-related side effects were evaluated.

RESULTS

Compared with the Control Group, the visual analogue scale scores were statistically lower in the ESP Group during all measurements of time, both at rest and active movement (P < 0.05). Tramadol consumption was lower in the ESP Group compared with the Control Group at all time periods (P < 0.05). Twenty-four hour tramadol consumption in the Control Group was significantly higher compared with the ESP Group (370.33 ± 73.27 mg and 268.33 ± 71.44 mg; P < 0.001, respectively) and the difference was 28%, and time to first analgesic requirement was significantly longer in the ESP Group than in the Control Group.

CONCLUSIONS

ESP block can be used in multimodal analgesia practice to reduce opioid consumption and relieve acute postoperative pain in patients undergoing open lumbar decompression surgery.

Ultrasound-guided Low Thoracic Erector Spinae Plane Block for Effective Postoperative Analgesia after Lumbar Surgery: Report of Five Cases

Pain control is an important administration of postoperative management in lumbar spinal surgery, and multimodal analgesia is most likely an important strategy in reducing postoperative spinal surgery. Erector spinae plane (ESP) block is a recently described regional anaesthesia technique that blocks the dorsal and ventral rami of the spinal nerves and the sympathetic nerve fibers. While the ESP block has been shown to provide effective postoperative analgesia after thoracic, breast, and abdominal surgery in case reports and randomised controlled studies, there are only a few case series that report that an ultrasonography (US)-guided bilateral ESP block provides effective postoperative analgesia in lumbar surgery. We report five patients undergoing lumbar surgery in which a bilateral lower thoracic ESP block was used as the postoperative analgesia. The bilateral ESP block may be a promising anesthetic method for postoperative analgesia following lumbar surgery. Our aim is testing the safety and efficacy of this technique in various surgical procedures by conducting prospective studies.

Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery

Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.

[Ultrasound-guided penile nerve block for pediatric hypospadias surgery]

An ultrasound-guided dorsal penile nerve (DPN) block was performed for postoperative analgesia in a 6-year-old, 19 kg, American Society of Anesthesiologists class II patient undergoing hypospadias surgery. The block was applied following the induction of general anesthesia. Anesthesia maintenance was provided with sevoflurane 2% in a 1:2 ratio of oxygen and nitrous oxide. The DPN block was performed using 0.2 mL/kg of 0.25% bupivacaine. Almost 24 hours of analgesia was provided following surgery.

Comparison of tidal volume and deep breath preoxygenation techniquesundergoing coronary artery bypass graft surgery: effects of hemodynamicresponse and arterial oxygenation

Background/aim: Different techniques exist for the preoxygenation of patients that will be operated on under general anesthesia. Preoxygenation with the deep breath (DB) method may affect cardiovascular stability, which is crucial for coronary artery bypass graft (CABG) patients. In this study, we aimed to compare the effects of the 3 min TVB preoxygenation technique and 1 min 8DBs technique on hemodynamic response and arterial oxygenation in patients with normal ejection fraction that were scheduled for elective CABG surgery. Materials and methods: Forty patients classified as ASA II?III and scheduled for elective CABG surgery were randomly assigned to TVB/3 min or 8DBs/1 min for preoxygenation. Cardiovascular variables, i.e. heart rate, mean arterial pressure, central venous pressure, cardiac index, systemic vascular resistance index, and stroke volume index, and arterial blood gas samples were analyzed before and after preoxygenation and at the end of the apneic period before intubation. Results: The preoxygenation methods affected the hemodynamic response similarly. PaO2 increased significantly with 8DBs compared to the TVB at the end of preoxygenation but was similar between the groups at the end of the apneic period (respectively, P: 0.03; P: 0.15). PaCO2 changes were similar between the groups. Conclusion: In patients with normal ejection fraction scheduled for CABG, 8DBs can be an alternative to TVB preoxygenation. Our results should be compared with those of other studies.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Serum levels of nitrate, nitrite and advanced oxidation protein products (AOPP) in patients with nonalcoholic fatty liver disease

BACKGROUND

Oxidative stress is increased and anti-oxidant defense mechanisms are impaired in patients with hepatosteatosis. The aim of the present study was to evaluate the serum levels of several oxidant and anti-oxidant markers in patients with nonalcoholic fatty liver disease (NAFLD).

PATIENTS AND METHODS

Thirty-four patients with NAFLD, and 19 healthy controls were included. In this study, we measured serum nitrate and advanced oxidation protein product (AOPP) as the oxidizing products and nitrite as the anti-oxidizing marker. Nitrate and nitrite levels were measured using a calorimetric method, and levels of serum AOPP were measured by a spectrophotometric method using a commercial ELISA kit.

RESULTS

Serum nitrate and AOPP levels were significantly higher in the NAFLD group compared to the control group. Serum nitrite and N-N levels were similar between the two groups. Serum nitrate and N-N levels were found to be significantly higher in patients with elevated ALT levels compared to patients with normal ALT levels. Serum nitrite and AOPP levels were comparable between these groups. Mean platelet volume (MPV) was significantly lower in the NAFLD group compared to the control group.

CONCLUSIONS

Serum levels of oxidizing agents including nitrate and AOPP increase in patients with NAFLD. In contrast, serum nitrite, an antioxidant agent, does not adequately increase to compensate for the oxidizing effects in these patients.

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.

Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Religious Orientation and Mental Health: A Study with Turkish University Students

The present study examined the relationship between religious orientation and mental health symptoms among Turkish students. A total of 341 undergraduate students between the ages of 18 and 26 completed the Brief Symptom Inventory and Age Universal Intrinsic-Extrinsic Scale. Extrinsic orientation was found to be correlated positively with symptoms of anxiety and depression. There were also significant correlations between hostility scores and both intrinsic and extrinsic religious orientations. Patterns were similar to those reported previously, but correlations were mostly in the .10–.14 range. In multiple-regression models, extrinsic orientation emerged as the only significant predictor for hostility, anxiety, and depression; however, only 2% of the variance was explained.

Comparison of the tuberculin skin test and the quantiferon test for latent Mycobacterium tuberculosis infections in health care workers in Turkey

The aim of this study was to compare the efficacy of the tuberculin skin test (TST) and the quantiferon test (QFT) for detecting latent tuberculosis infection (LTBI) in health care workers (HCWs). Seventy-six participants who were working in Duzce University Hospital, where tuberculosis patients were being treated, were included in the study. TST was performed according to the Mantoux technique. QFT was performed in accordance with the manufacturer's instructions. A positive TST result was defined as an induration diameter of > or = 15 mm. TSTs were positive in 41 of 76 participants (53.9%) and QFT was positive in 65 of 76 participants (85.5%). There was a significant difference between the numbers of QFT-positive and TST-positive cases (P=0.02). When the induration diameter of TST was > or = 20 mm, QFT positivity was 100%. Multivariate analysis revealed that there was a significant correlation between the percentage of patients with QFT positivity and the induration diameter of TST (P=0.009). QFT thus seems to be more effective for LTBI diagnosis than TST. However, large-scale trials including quantitative measurement of QFT in subgroups taking into account the division where HCWs are employed and the different results of TST might clarify the usefulness of QFT in LTBI diagnosis.

Androgenic adult granulosa cell tumor in a teenager: a case report and review of the literature

The clinicopathologic findings of the third case of androgenic adult granulosa cell tumor in patients younger than 15 years was presented and discussed in the light of the literature. A patient complaining of secondary amenorrhea and hirsutism with elevated levels of plasma total testosterone, dehydroepiandrosterone sulfate, free androgen index and serum inhibin A, and a left ovarian septated, cystic mass was admitted to the hospital. The inhibin A level was within normal levels in the first month postoperatively. Inhibin A could be a tumor marker of utmost importance particularly in patients with androgenic or hyperestrogenic symptoms, especially in cases where benign criteria are abundant such as young age, nonincreased levels of classic tumor markers, and ultrasonographic appearance without any suspicion of malignancy.

Androgenic adult granulosa cell tumor in a teenager: a case report and review of the literature

The clinicopathologic findings of the third case of androgenic adult granulosa cell tumor in patients younger than 15 years was presented and discussed in the light of the literature. A patient complaining of secondary amenorrhea and hirsutism with elevated levels of plasma total testosterone, dehydroepiandrosterone sulfate, free androgen index and serum inhibin A, and a left ovarian septated, cystic mass was admitted to the hospital. The inhibin A level was within normal levels in the first month postoperatively. Inhibin A could be a tumor marker of utmost importance particularly in patients with androgenic or hyperestrogenic symptoms, especially in cases where benign criteria are abundant such as young age, nonincreased levels of classic tumor markers, and ultrasonographic appearance without any suspicion of malignancy.

Candida carriage and Candida dubliniensis in oropharyngeal samples of type-1 diabetes mellitus patients

The carriage of Candida dubliniensis in the oral cavities of type-1 diabetic patients were investigated. Of 230 patients 81 (35%) had Candida spp. in their oral cavity; C. albicans was the most frequently isolated species (58%). No C. dubliniensis was found in the study population.

A case of epididymo-orchitis and paravertebral abscess due to brucellosis

Brucellosis is a zoonotic infection involving many systems and it is widespread in Turkey. Involvement of muscular and skeletal systems is a common complication of brucellosis. Involvement of genitourinary system (epididymo-orchitis) is a rarer complication (Sözen TH. Infeksiyon Hastaliklari. 1996; pp. 486-493; Edward J. Young. Principles and Practice of Infectious Diseases, Vol. 2, 5th edn. 2000; pp. 22386-22393). Brucellosis accompanied by abscess formation in the vertebra is frequently seen in the elderly and patients with a chronic disease (Sözen TH. Infeksiyon Hastaliklari. 1996; pp. 486-493; Edward J. Young. Principles and Practice of Infectious Diseases, Vol. 2, 5th edn. 2000; pp. 22386-22393; Af-Eissa YA, Kambal AM et al. Ann Rheum Dis 1990;49 : 896-900; Colmenore JD, Cisneron JM, Orjuela DL et al. Infection 1992; 20: 38-42). Brucellosis accompanied by paravertebral abscess and epididymo-orchitis is extremely rare. In this report, we present a case of epididymo-orchitis and paravertebral abscess due to brucellosis.

Relationships between depression and attachment styles in parent- and institution-reared Turkish children

The present study, using a sample of Turkish children, aimed to test two attachment-theory predictions: (a) institution-reared children who were separated from their parents at an early age are less likely to have secure attachment schemata than children from two-parent families, and (b) depressive schemata are positively related to insecure attachment schemata and negatively related to secure attachment schemata. Following a systems-theory perspective, we also predicted that the relationship between depression and attachment styles would be stronger for institution-reared children than for children from two-parent families. Hazan and Shaver's (1987) attachment-style items and the Beck Depression Inventory were administered to 20 institution-reared and 20 parent-reared boys by a female interviewer. The results supported the first two predictions of the study.