Comparison of the therapeutic efficacy of topical tranexamic acid, epinephrine, and lidocaine in stopping bleeding in non-traumatic epistaxis: a prospective, randomized, double-blind study.

OBJECTIVE: Nasal packing is used to stop bleeding in cases of epistaxis. Different topical drugs are preferred to these packs in the emergency department. In this study, we aimed to compare the efficacy of lidocaine, epinephrine and tranexamic acid (TXA) in stopping bleeding in patients with epistaxis. PATIENTS AND METHODS: Patients with non-traumatic epistaxis were evaluated in three treatment groups as topical lidocaine, epinephrine, and TXA. These treatments were applied prospectively in a double-blind manner and randomized manner. The bleeding stop times of the patients were recorded with bleeding time parameters. RESULTS: A total of 108 patients were included in the study. The mean age of the patients was 55.7±17.7 years. When the bleeding stop times were compared between the groups, there was no statistically significant difference (lidocaine vs. epinephrine, p=0.870; lidocaine vs. TXA, p=0.502; and epinephrine vs. TXA, p=0.242). The systolic blood pressure value statistically significantly differed between the lidocaine and epinephrine groups (p=0.034) and between the epinephrine and TXA groups (p=0.003). There was also a statistically significant difference between the diastolic blood pressure values of the epinephrine and TXA groups (p=0.020). CONCLUSIONS: We found that nasal packing with lidocaine, epinephrine and TXA was not superior to each other in terms of stopping bleeding time.

Comparative genetics of scyphozoan species reveals the geological history and contemporary processes of the Mediterranean Sea.

Jellyfish are useful genetic indicators for aquatic ecosystems as they have limited mobility and are highly exposed to the water column. By using comparative genomics and the molecular clock (timetree) of Rhizostoma pulmo, we revealed a divergence point between the East and West Mediterranean Sea (MS) populations that occurred 4.59 million years ago (mya). It is suggested that the two distinct ecological environments we know today were formed at this time. We propose that before this divergence, the highly mixed Atlantic and Mediterranean waters led to the wide dispersal of different species including R. pulmo. At 4.59 mya, the Western and Eastern MS were formed, indicating the possibility of a dramatic environmental event. For the first time, we find that for the jellyfish we examined, the division of the MS in east and west is not at the Straits of Sicily as generally thought, but significantly to the east. Using genomics of the Aurelia species, we examined contemporary anthropogenic impacts with a focus on migration of scyphozoa across the Suez Canal (Lessepsian migration). Aurelia sp. is among the few scyphozoa we find in both the MS and the Red Sea, but our DNA analysis revealed that the Red Sea Aurelia sp. did not migrate or mix with MS species. Phyllorhiza punctata results showed that this species was only recently introduced to the MS as a result of anthropogenic transportation activity, such as ballast water discharge, and revealed a migration vector from Australia to the MS. Our findings demonstrate that jellyfish genomes can be used as a phylogeographic molecular tool to trace past events across large temporal scales and reveal invasive species introduction due to human activity.

Social involvement, socio-economic status and subjective well-being of parents of offspring with intellectual and developmental disabilities.

BACKGROUND: The study explores whether households' socio-economic status and social involvement can moderate the association between stress and subjective well-being among parents of offspring with intellectual and developmental disabilities (IDD). METHOD: The random national sample comprised 301 parents caring for offspring with IDD. Measurements consist of a household income survey, a questionnaire on resources and stress, a social involvement questionnaire and a personal well-being index. Using PROCESS software, a regression-based path analysis has been used to test the moderating effect of social involvement and socio-economic status on the association between stress and subjective well-being. RESULTS: Social involvement moderated the association between parental stress and subjective well-being. At high levels of parental stress only, parents with increased social involvement reported better subjective well-being. Significant interaction was observed between stress and socio-economic status. CONCLUSIONS: Among parents raising offspring with IDD, social involvement may enhance the relationship between parental stress and subjective well-being. At lower stress levels, better socio-economic status is associated with increased subjective well-being.

An Autopsy Series: Lightning-related Deaths in Van and Hakkâri Provinces, Turkey

ABSTRACT Objective: To report the largest series of lightning-related deaths in Turkey, to review the literature on this subject, and to identify similarities and differences between the autopsy findings in this study and the information available in literature. Methods: In this study, autopsy reports and crime scene investigation data on 11 lightning-related fatalities that occurred in the Van and Hakkâri Provinces, Turkey, from January 1, 2011 to December 31, 2015 were retrospectively reviewed. Results: Of the 1699 fatalities, 11 (2.53%) evaluated by medico-legal autopsy in the Van and Hakkâri Province in a 5-year period died from lightning strikes. Of these cases, 10 (90.1%) were males and 1 (9.9%) was female (p < 0.05). All cases were in the 11 to 33 years age group. All cases were injured outdoors. Conclusion: We concluded that deaths due to lightning strikes are relatively rare in Turkey, and may be reduced with precautions such as avoiding staying under trees or in the vicinity of high towers, refraining from touching metal objects, avoiding lying on the ground, leaning on walls, and crouching outdoors.

Limitations of cadaveric organ donation on judicial cases and problems confronted in autopsy: Istanbul data in comparative perspective.

Organ transplantation is one of the most important services of modern medicine to the humanity. In judicial death cases the interaction between judicial needs and transplantation needs is inevitable and both should be provided in a short time before the decomposition of the body. Thus, the description of this interaction and the algorithm which should be carried out to manage these cases are important. Aim of this study is to determine the problems confronted in forensic autopsies and to determine what to do for both judicial processes' and cadaveric organ donations' not becoming limited due to each other. With these aims, autopsy case archive of the Council of Forensic Medicine Istanbul Morgue Department was reviewed, between the years 2009 and 2011, to reveal the number of organ donors among autopsy cases and also to find out the judicial problems confronted during autopsies. Among 12,016 judicial death cases referred to Istanbul Morgue Department in 3 years, 35 cases were found to have undergone cadaveric solid organ harvesting procedure and 307 cases cornea-only harvesting procedure. Manner of deaths for organ donor cases were blunt trauma due to traffic accident in 20 cases, firearm injury in 3 cases, stabbing in 2 cases, suspicious criminal battery in 4 cases and fatal falls in 5 cases. Only 1 case was suspected to have died due to high dose insulin administration. Through the whole data presented in this study, it can be concluded that consulting with the Forensic Medicine Expert not only for the autopsies but also during the clinical process of a judicial case, who is a candidate to be an organ donor, is absolutely important. The early contribution of the Forensic Medicine Expert would provide help to plan both the judicial process and the transplantation process which needs urgent decisions. A Forensic Medicine Expert may be an organ harvest team member performing initial investigations on the cause of death and collecting some of the toxicological screening samples when needed.

Stroke in the very elderly: characteristics and outcome in patients aged ≥85 years with a first-ever ischemic stroke.

BACKGROUND: Epidemiological and clinical features of very elderly patients with stroke are still uncertain. Our aim was to study the patient characteristics and outcomes in the very elderly (aged ≥85 years) with a first-ever ischemic stroke in the National Acute Stroke Israeli Survey (NASIS) registry. METHODS: The NASIS registry is a nationwide prospective hospital-based study performed triennially (2004, 2007, 2010). Patients with ischemic stroke aged ≥85 years were compared with those 65-84 years old regarding their baseline characteristics, stroke severity, etiology of stroke and stroke outcomes. Logistic regression analyses were used to adjust for potential confounders. Stroke severity was determined according to the National Institute of Health Stroke Scale (NIHSS) score. RESULTS: The proportion of very elderly (≥85 years) patients among the NASIS population increased from 18.3% in 2004 to 19.9% in 2007 and 24.5% in 2010 (p for trend = 0.005). The percentage of women was higher in patients aged ≥85 years (p < 0.0001). Atrial fibrillation, congestive heart disease and prior disability were significantly more common, while diabetes, current smoking and dyslipidemia were less frequent in the very elderly. The very elderly presented with more severe strokes: 36.3% of the ≥85-year-old patients had an NIHSS score ≥11 compared with 22.0% in the younger age group (p < 0.05). CONCLUSIONS: There is an increasing proportion of very elderly subjects, mostly women, among first-ever ischemic stroke patients. Current information on age-specific aspects of stroke in the very elderly is crucial to set up successful prevention pathways and implementing well-organized stroke care for this population.

Vasomotor reactivity as a predictor for syncope in patients with orthostatism.

OBJECTIVES: Syncope in patients with orthostatic hypotension (OH) may be the result of impaired cerebral autoregulation. Cerebral autoregulation status can be determined by assessing cerebral vasomotor reactivity (VMR). We assessed and compared VMR in patients with OH with and without syncope. MATERIAL AND METHODS: Twenty-nine patients with OH underwent transcranial Doppler (TCD) and the Diamox test (1 g acetazolamide IV) for assessing VMR during elaboration of their OH syndrome. The percent difference between cerebral blood flow velocities (BFV) in the middle cerebral (MCA) and vertebral (VA) arteries before and after acetazolamide was defined as VMR%. We considered increases of BFV of ≥ 40% as being indicative of good VMR and classified our study patients as having good or impaired VMRs accordingly. RESULTS: Mean VMR% values of the MCA and VA in patients with OH with syncope (n = 12) were significantly lower as compared with patients with OH without syncope (n = 17): 25.2 ± 20.5% and 42.5 ± 18.6%; 20.9 ± 15.5% and 40.8 ± 28.5%, respectively (P < 0.05). CONCLUSIONS: Among patients with OH, we found an association between the presence of syncope and impaired VMR. Assessment of VMR among patients with OH may predict those who are at higher risk to faint and fall and to support more aggressive intervention.

Can the patient-reported outcome instruments determine disease activity in rheumatoid arthritis?

OBJECTIVES: The aim of this study was to investigate the indicative value of the patient-reported outcome instruments (PROs) on disease activity in rheumatoid arthritis (RA). METHODS: Three hundred sixty eight patients with RA were included in this cross-sectional study. Disease activity was evaluated using both the Disease Activity Score 28 (DAS 28) and the Clinical Disease Activity Index (CDAI). Patients who had DAS 28 score < 3.60 points and CDAI score <10.00 points were allocated into the "low disease activity" group and those who had DAS 28 score > or = 3.60 points and CDAI score > or = 10.00 points into the "moderate or high disease activity" group. The Health Assessment Questionnaire (HAQ), Nottingham Health Profile (NHP), Rheumatoid Arthritis Quality of Life (RAQoL), and Short Form 36 (SF 36) were used as PROs. Logistic regression analysis was used to find variables, which had an indicative value for disease activity. RESULTS: HAQ, pain and emotional reaction subscales of NHP, and bodily pain, general health and social functioning subscales of SF 36 had independent indicative values, when DAS 28 was used as dependent variable. On the other hand, HAQ, pain and emotional reaction subscales of NHP, and general health and emotional role limitation subscales of SF 36 had indicative values when CDAI was used as dependent variable. DAS 28 and CDAI both showed HAQ as the parameter with the highest odds ratio (OR). But RAQoL had shown no independent indicative value for projecting disease activity. CONCLUSION: It was concluded that HAQ could determine disease activity in RA better than other PROs included in this study (Tab. 4, Ref. 36).

Characteristics of first ever ischemic stroke in the very elderly: profile of vascular risk factors and clinical outcome.

PURPOSE: Age is the most significant non-modifiable risk factor for ischemic stroke (IS). With increasing expectancy of life, the majority of IS patients will be elderly subjects. We studied the epidemiological, clinical and rehabilitation features of patients aged ≥85 years with first-ever IS. METHODS: Demographic data, prevalence of risk factors, etiology of stroke, severity of neurological deficit, major complications and mortality rates were collected from a hospital-based stroke registry and compared between patients at the age of 65-84 and ≥85. Clinical assessment was performed by means of the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS). RESULTS: Among 216 patients aged ≥85 years there was significantly higher proportion of a history of atrial fibrillation than in 128 patients at the age of 65-84 years and lower prevalence of hypertension, diabetes mellitus, hyperlipidemia and smoking. Large artery atherosclerosis was more frequently identified in the older patients (49% vs. 32%, p=0.002). Although NIHSS scores on admission were lower in the older patients they were more disabled at discharge. CONCLUSIONS: With respect to the patients aged <85 years very old IS patients showed different vascular risk factors profile, clinical and rehabilitation course. These findings suggest specializing stroke care in the very elderly.

School environment and sanitation in rural India.

CONTEXT: A school child educated about the benefits of sanitation and good hygiene behavior is a conduit for carrying those messages far beyond the school walls, bringing lasting improvement to community hygienic practices. AIMS: To study the status of school environment and sanitation in rural India. SETTINGS AND DESIGN: Government schools in rural Karnataka, cross sectional study. MATERIALS AND METHODS: Twenty schools were randomly selected for the study. Informed consent was taken from the Heads of the schools. A pre tested close ended questionnaire was used to get the information. The minimum standards for sanitation of the school and its environment in India were used as the guiding principles to evaluate the appropriateness/ adequacy of the various attributes. STATISTICAL ANALYSIS USED: Percentages and proportions. RESULTS: Out of 20 schools selected, one fourth of the schools were located/ sited at inappropriate places. Only half of the schools had appropriate/ adequate structure. Eighteen (90%) of the schools were overcrowded. Ventilation and day light was adequate for 12(60%) and 14(70%) of the schools respectively. Cleanliness of school compound/classrooms was adequate in 80% of the schools. There were no separate rooms for serving the midday meals in any of the schools under study. Eighteen (90%) of the schools were having drinking water points. Liquid and solid waste disposal was insanitary in six (30%) and eight (40%) of the schools respectively. Only half of the schools had adequate latrines for boys and 60% for girls. Only two (10%) of the schools had adequate hand washing points with soap. CONCLUSIONS: Environment and sanitation facilities at many of the schools are not fully satisfactory.

Long-term follow-up of patients with asymptomatic occlusion of the internal carotid artery with good and impaired cerebral vasomotor reactivity.

BACKGROUND: Cerebral hemodynamic status might be prognostic for either the symptomatic or asymptomatic course of carotid occlusive disease. It is determined by evaluating cerebral vasomotor reactivity (VMR). We assessed VMR in asymptomatic patients with total occlusion of the internal carotid artery (ICA) and followed them to evaluate the role of impaired VMR in predicting ischaemic stroke (IS). METHODS: Thirty-five patients (21 men, mean age ± SD 68 ± 7.5 years) with unilateral asymptomatic ICA occlusion were studied by transcranial Doppler and the Diamox test (intravenous 1.0 g acetazolamide) and followed for 48 months or until reaching the end-points of IS, transient ischaemic attack, or vascular death. VMR% was evaluated by recording the percent differences in peak systolic blood flow velocities in each middle cerebral artery at baseline and after Diamox administration. RESULTS: Based on VMR% calculations, 14 (40%) patients had good VMRs and 21 (60%) had impaired VMRs. The global annual risk of ipsilateral ischaemic events was 5.7%. The annual ipsilateral ischaemic event risk was 1.8% in patients with good VMRs, whilst it was 7.1% in patients with impaired VMRs. An impaired VMR was significantly correlated with ipsilateral IS (Kaplan-Meier log rank statistic, P = 0.04). CONCLUSIONS: Our results support the value of VMR assessment for identifying asymptomatic patients with carotid occlusion who belong to a high-risk subgroup for IS. New trials using extracranial-to-intracranial bypass surgery in patients with asymptomatic ICA occlusion and impaired VMRs are warranted.

Validation of breast cancer nomograms for predicting the non-sentinel lymph node metastases after a positive sentinel lymph node biopsy in a multi-center study.

OBJECTIVE: In the study, our aim was to evaluate the predictability of four different nomograms on non-sentinel lymph node metastases (NSLNM) in breast cancer (BC) patients with positive sentinel lymph node (SLN) biopsy in a multi-center study. METHODS: We identified 607 patients who had a positive SLN biopsy and completion axillary lymph node dissection (CALND) at seven different BC treatment centers in Turkey. The BC nomograms developed by the Memorial Sloan Kettering Cancer Center (MSKCC), Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. Area under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for each nomogram and values greater than 0.70 were accepted as demonstrating good discrimination. RESULTS: Two hundred and eighty-seven patients (287) of 607 patients (47.2%) had a positive axillary NSLNM. The AUC values were 0.705, 0.711, 0.730, and 0.582 for the MSKCC, Cambridge, Stanford, and Tenon models, respectively. On the multivariate analysis; overall metastasis size (OMS), lymphovascular invasion (LVI), and proportion of positive SLN to total SLN were found statistically significant. We created a formula to predict the NSLNM in our patient population and the AUC value of this formula was 0.8023. CONCLUSIONS: The MSKCC, Cambridge, and Stanford nomograms were good discriminators of NSLNM in SLN positive BC patients in this study. A newly created formula in this study needs to be validated in prospective studies in different patient populations. A nomogram to predict NSLNM in patients with positive SLN biopsy developed at one institution should be used with caution.

Ovotesticular disorder of sex development with a prostatic gland and review of literature.

Ovotesticular disorder of sex development (OTDSD) is a rare condition and defined as the presence of ovarian and testicular tissue in the same individual. Most of patients with OTDSD have female internal genital organs. In this report, we present a case in which, we demonstrated prostate tissue using endoscopic and radiologic methods in a 46-XX, sex determining region of the Y chromosome negative male phenotypic patient, with no female internal genitalia. Existence of prostate in an XX male without SRY is rarely seen and reveals a complete male phenotype. This finding is critical to figure out what happens in embryonal period.

The relation between preoperative ultrasonographic thyroid volume analysis and thyroidectomy complications.

OBJECTIVE: To determine the relation between thyroid volume (ThV) and thyroidectomy complications using preoperative ultrasound and ellipsoid volumetric analysis in Turkish patients. PATIENTS AND METHODS: This prospective study included a total of 500 patients (401 females = 80.2% and 99 males = 19.8%) who were operated for benign goiter. According to their ThV estimated by ultrasound hey were classified in three groups: 1. less than 50 ml (n = 269; 53.8%), 2. between 50 and 100 ml (n = 151; 30.2%), 3. more than 100 ml (n = 80; 15.6%). By comparing the association of thyroid volume with peroperative and postoperative complications it was evaluated whether the thyroid volume could be an effective factor participating in morbidity and mortality of patients. RESULTS: Total peroperative complication rate was 2% (n = 10) with trachea injury in 2 (0.4%), bleeding in 8 (1.6%) patients. Peroperative complications were significantly more frequent in patients with large volume (p = 0.003). Temporary hypocalcemia rate in patients with less than 50 ml volume was highly significant (p < 0.001). Volume average was low in patients with hypocalcemia as compared to patients without hypocalcemia (p < 0.001). Both the temporary and permanent vocal cord paralysis (VCP) were significantly more frequent in patients with larger volumes (p = 0.002). All four patients with permanent VCP had more than 100 ml volume. CONCLUSION: Thyroid volume is an important factor affecting thyroidectomy complications. In patients with smaller ThV increased risk of hypocalcemia was found, whereas in those with larger ThV increased risk of recurrent nerve damage and peroperative bleeding was observed.

Intraductal location of the sclerosing adenosis of the breast.

Sclerosing adenosis is a benign breast disease with non-specific images on ultrasound or mammogram. It can mimic infiltrating carcinoma when the above mentioned imaging techniques are used. Herein we present a patient with breast cancer who received neoadjuvant chemotherapy and subsequently underwent mastectomy. Ductoscopy was performed to the mastectomised breast specimen as per the ductoscopy research protocol. Ductoscopy revealed several nodular lesions in the duct with no additional demonstrable intraductal pathology. The lesions were reported as sclerosing adenosis by pathologist. As to our knowledge, this is the first case in literature that demonstrates the use of ductoscopy in diagnosing the sclerosing adenosis in the breast tissue. Ductoscopy and development of ductoscopy guided biopsy techniques may be used as an early diagnostic method for the ductal breast lesions (Fig. 2, Ref. 10). Full Text (Free, PDF) www.bmj.sk.

The efficacy of Nutrition Risk Screening-2002 (NRS-2002) to decide on the nutritional support in general surgery patients.

INTRODUCTION: Nutritional Risk Screening-2002 (NRS-2002) has been recently used to evaluate the nutritional status of patients according to the recommendation of ESPEN. In this prospective study, we aimed to find the effectiveness of NRS-2002 on preoperative patients who were candidates for elective procedure at a general surgery clinic. MATERIAL AND METHOD: The NRS-2002 scores of 698 patients were recorded in first 24 hours subsequent to their admission to hospital. The patients who had NRS-2002 score of 3 or 4 were accepted, and the scores were correlated with their age and clinical diagnosis. RESULTS: The nutritional status was good in 655 (93.9%) patients, and 43 patients (6.1%) were malnourished. A total of 135 patients had malignant disorders, among them 37 had concomitant malnutrition. The rate of malnutrition was 28.1% in patients with malignancy. The latter rate was 1.1% in patients with benign disorders. In patients who had gastrointestinal malignancy, the malnutrition rate was 31% (35/89), and the latter ratio was 6.5% (3/46) in patients who had malignancies arising from other than the gastrointestinal system. The NRS-2002 score was changed significantly according to age and malignancies (p<0.05). CONCLUSION: NRS-2002 can be easily used to evaluate the nutritional status of patients. This system is significant in deciding on nutritional support (Tab. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Poverty, tobacco, and health: an Indian scenario.

Poverty and health have a two-way relationship. Poverty increases the vulnerability of people to disease, and sickness affects their income leading to poverty. Tobacco has been identified as a major avoidable cause of illness and premature death. In India, more than half of men and one-tenth of women use one or more forms of tobacco. Tobacco-use shows a clear and continual increase with decreasing wealth quintiles. Poor smokers, who are at a greater risk of illness, are also at a greater risk of not being treated or of falling into greater poverty if they seek treatment. Poor people spend money on tobacco that could be spent on food, shelter, education, and healthcare. These decisions can entrench families in an ongoing cycle of poverty and ill-health. The direct and indirect costs of tobacco-use are immense for national economy. This has positioned control of tobacco relevant in India's per suite to achieve the goals of poverty eradication and health for all.

Climate change and health: Why should India be concerned?

Overwhelming evidence shows that climate change presents growing threats to public health security - from extreme weather-related disasters to wider spread of such vector-borne diseases as malaria and dengue. The impacts of climate on human health will not be evenly distributed around the world. The Third Assessment Report (Intergovernmental Panel on Climate Change-2001) concluded that vulnerability to climate change is a function of exposure, sensitivity, and adaptive capacity. Developing country populations, particularly in small island states, arid and high mountain zones, and in densely populated coastal areas are considered to be particularly vulnerable. India is a large developing country, with the Great Himalayas, the world's third largest ice mass in the north, 7500 km long, and densely populated coast line in the south. Nearly 700 million of her over one billion population living in rural areas directly depends on climate-sensitive sectors (agriculture, forests, and fisheries) and natural resources (such as water, biodiversity, mangroves, coastal zones, grasslands) for their subsistence and livelihoods. Heat wave, floods (land and coastal), and draughts occur commonly. Malaria, malnutrition, and diarrhea are major public health problems. Any further increase, as projected in weather-related disasters and related health effects, may cripple the already inadequate public health infrastructure in the country. Hence, there is an urgent need to respond to the situation. Response options to protect health from effects of climate change include mitigation as well as adaptation. Both can complement each other and together can significantly reduce the risks of climate change.

Models for predicting non-sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system.

BACKGROUND: Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non-sentinel nodes and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. To predict non-SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created. METHOD: This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non-SLN involvement in patients with SLN positive breast cancer. RESULT: There are several published scoring systems that contain different parameters to estimate the rate of non-SLN metastases in SLN positive patients. We reviewed Memorial Sloan-Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non-SLN status accurately. The other three models have not yet been verified in outside institutions. CONCLUSION: Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.