In-Hospital Bleeding in Elderly Patients With Acute Coronary Syndrome: Are Potent Antiplatelet Agents Safe?

Despite implementation of new interventional techniques and therapeutic advances, elderly patients with acute coronary syndrome (ACS) continue to be susceptible to in-hospital bleeding compared with younger ones. Thus, we investigated the incidence of in-hospital bleeding events and associated risk factors in elderly (≥ 75°years) ACS patients. We also wanted to define the bleeding sites, characteristics, and associated mortality. Bleeding Academic Research Consortium (BARC) classification type 2, 3, or 5 was used to define bleeding events. Overall, 539 patients were included in the study (mean age: 82.5 ± 4.8°years; 282 (52.3%) females). Of these patients, 69 (12.8%) developed in-hospital bleeding. Factors that were independently related with in-hospital bleeding were age (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.011.14, P = .01), acute kidney injury (OR: 3.66; 95% CI: 2.016.69; P < .01), tirofiban (OR: 4.43; 95% CI: 1.7810.99; P < .01), and ticagrelor (OR: 1.93; 95% CI: 1.013.73; P = .04) administration. The urinary tract was the most frequent bleeding site, followed by femoral arteries. In conclusion, ticagrelor and tirofiban should be used with caution in elderly ACS patients.

Serum VEGF-C levels as a candidate biomarker of hypervolemia in chronic kidney disease.

Attaining and maintaining optimal "dry weight" is one of the principal goals during maintenance hemodialysis (MHD). Recent studies have shown a close relationship between Na load and serum vascular endothelial growth factor-C (VEGF-C) levels; thus, we aimed to investigate the role of VEGF-C as a candidate biomarker of hypervolemia. Physical examination, basic laboratory tests, N-terminal pro b-type natriuretic peptide (NT-ProBNP), echocardiography, and bioimpedance spectroscopy data of 3 groups of study subjects (euvolemic MHD patients, healthy controls, and hypervolemic chronic kidney disease [CKD] patients) were analyzed. Research data for MHD patients were obtained both before the first and after the last hemodialysis (HD) sessions of the week. Data of 10 subjects from each study groups were included in the analysis. Serum VEGF-C levels were significantly higher in hypervolemic CKD versus in MHD patients both before the first and after the last HD sessions (P = .004 and P = .000, respectively). Healthy controls had serum VEGF-C levels similar to and higher than MHD patients before the first and after the last HD sessions of the week (P = .327 and P = .021, respectively). VEGF-C levels were correlated with bioimpedance spectroscopy results (r 0.659, P = .000) and edema (r 0.494, P =0.006), but not with ejection fraction (EF) (r -0.251, P = .134), blood pressures (systolic r 0.037, P = 0.824, diastolic r -0.067, P = .691), and NT-ProBNP (r -0.047, P = .773). These findings suggest that serum VEGF-C levels could be a potential new biomarker of hypervolemia. The lack of correlation between VEGF-C and EF may hold a promise to eliminate this common confounder. Further studies are needed to define the clinical utility of VEGF-C in volume management.

Effects of Smoking on Central Corneal Thickness and the Corneal Endothelial Cell Layer in Otherwise Healthy Subjects.

OBJECTIVES: The effects of smoking on central corneal thickness (CCT), corneal endothelial cell density (ECD), and morphology were evaluated in otherwise healthy subjects. METHODS: The study included 103 current smokers and 106 healthy nonsmoking subjects without any eye disease apart from refractive errors. Endothelial cell density, percentage of hexagonality, and coefficient of variation (CV) in cell size were measured using noncontact specular microscopy. Central corneal thickness was measured by ultrasound pachymetry. RESULTS: The mean age of participants in the nonsmoker group was 31.4 ± 5.1 years (18-60) and 33.0±9.1 years (18-58) in the current smoker group. The mean CCT value was 523.7±34 µm in the nonsmoker group and 518.5±37 µm in the smoker group. The mean ECD, CV, and percentage of hexagonality values were 2,881±293.7 cells per square millimeter, 32.5±6%, and 56.6±11% in the nonsmoker group, and 2,681±323.9 cells per square millimeter, 33.4±5%, and 55.5±10% in the smoker group, respectively. Although there was no difference between the groups in terms of CCT, CV, and percentage of hexagonality values, a significant difference was determined in the case of ECD values[ZERO WIDTH SPACE][ZERO WIDTH SPACE] (P<0.001). The smoker group comprised 67 light smokers (65.0%) and 36 (35.0%) heavy smokers. Between these groups, there was no statistically significant difference in the mean values of CCT, ECD, CV, and the percentage of hexagonality. CONCLUSIONS: Although cigarette smoking has no effect on cell polymorphism and polymegethism, the results suggest that smoking reduces endothelial cell count.

The effects of remifentanil and esmolol on increase in intraocular pressure due to laryngoscopy and tracheal intubation: a double-blind, randomized clinical trial.

PURPOSE: This study aimed to compare the effects of remifentanil and esmolol on the elevation of intraocular pressure (IOP) and hemodynamic response. METHODS: After approval of the institutional Ethics Committee and obtaining informed consent, 60 adult patients with American Society of Anesthesiologists I-II status undergoing elective, nonophthalmic surgery were included in the study. Exclusion criteria were preexisting eye disease, neuromuscular disease, esophageal reflux, hiatus hernia, allergy to any of the study drugs, and the use of ß-blockers, diuretics, or other antihypertensive agents. The patients were randomized into 2 groups by using the sealed-envelope method, as follows: group E (esmolol) and group R (remifentanil). A single intravenous dose of esmolol (0.5 mg/kg) or remifentanil (1 µg/kg) just before induction agents were given to patients in groups E and R, respectively. IOP, heart rate (HR), and mean arterial pressure (MAP) values were recorded before intubation and at 1, 3, 5, and 10 minutes after intubation. RESULTS: The IOP decrease in group R was statistically significant compared with group E (P<0.01). HR values at 10 minutes after intubation were significantly decreased in group E compared with group R (P<0.05). There was no significant difference in MAP values between the groups. CONCLUSIONS: It was concluded that remifentanil is more effective than esmolol in preventing IOP elevation related to laryngoscopy and tracheal intubation, while there is no significant difference between the 2 agents in terms of HR and MAP.

Impact of enuresis nocturna on health-related quality of life in children and their mothers.

OBJECTIVE: Nocturnal enuresis (NE) is a common childhood disorder. As children age and NE persists, it may become more stressful for both them and their caregivers. The aim of the present study was to assess the impact of NE on the quality of life of children who were diagnosed with NE, and their mothers, and to compare the results with a healthy control group. SUBJECTS AND METHOD: Eighty-two children with NE, and their mothers, and 93 healthy children and their mothers were enrolled in the study. The sociodemographic data were evaluated. The Pediatric Quality of Life Inventory 4.0 Scales (PedsQL 4.0) were used to assess the children's health-related quality of life (HRQoL); and the World Health Organization Quality of Life Instrument; short form (WHOQOL-BREF) was used for the mothers' HRQoL. RESULTS: The PedsQL 4.0 mean scores for the children with NE group were as follows: total score, 68.74; physical health score, 72.79; psychosocial health score, 66.56. The scores for the children in the control group were as follows: total score, 80.98; physical health score, 81.11; psychosocial health score, 80.88. The WHOQOL-BREF scores for the mothers of the children with NE were as follows: physical health score, 67.90; psychosocial health score, 62.66; social relationships score, 60.90; environmental area score, 61.04. The WHOQOL-BREF scores for the mothers in the control group were as follows: physical health score, 75.96; psychosocial health score, 72.39; social relationships score, 72.18; environmental area score, 67.44. CONCLUSIONS: Nocturnal enuresis negatively affects the quality of life of both children and their mothers. Therefore, when physicians see children with enuresis, they should also be aware of the effect of NE on the mothers' quality of life.

Vacuum-assisted continuous circular capsulorhexis using bimanual irrigation and aspiration system of phaco machine in immature cataract.

Seventy-eight eye of 65 patients were enrolled in this retrospective clinical study. Two-side ports are made with a 23-gauge stiletto knife. The irrigation handpiece is introduced into the anterior chamber through one side port and 27-gauge cystotome is introduced through the other one. Anterior capsular flap is created with cystotome. The capsular flap is vacuumed with a 25-gauge visco elastic's cannula, which connected to the phaco machine vacuum. The continuous circular capsulorhexis (CCC) is completed with the using bimanual irrigation and aspiration system of phaco machine. Vacuum-assisted CCC technique was used in 78 cases of uncomplicated immature senile cataracts. All cases were done under sub-Tenon's anesthesia. A complete CCC was achieved in all cases. Performing CCC with our technique is easy, safe, and cheap. It may be an alternative method to CCC by using OVD and forceps.

A new diagnostic approach for Turkish speaking populations DAWBA Turkish Version.

Aims. Turkey has the youngest population in Europe with about 25 million people aged below 19 years and Turkish-speaking people comprise the biggest migrant group in Europe with 2.5 million people dispersed in different countries, but conducting epidemiologic surveys on Turkish people is challenging due to the lack of a suitable diagnostic tool. The Development and Well-Being Assessment (DAWBA) is one of the most widely used diagnostic interviews in child and adolescent psychiatry. In this study, we aimed at translating the DAWBA into Turkish and then examined its validity and reliability. Methods. The validity of the Turkish version was examined in clinical (n = 50) and community (n = 104) samples. The interrater reliability was also evaluated on 20 cases. Results. The translation method used in the study achieved semantic, conceptual, content, technical, item and criterion equivalence between the Turkish and original forms. The validity of the Turkish DAWBA was good or excellent for different diagnostic categories (κ: 0.43-0.84); the interrater reliability was also excellent (κ: 0.85-1). Conclusions. The Turkish DAWBA may be useful for future prevalence studies in Turkey. European clinicians and researchers who work with Turkish-speaking families can use the online Turkish DAWBA to gather structured information from Turkish-speaking informants and review the answers in their own language.

Surgical implications of anatomical landmarks on the lateral surface of the mastoid bone.

The aim of this study was to examine the relationships of the surgical landmarks on the lateral surface of the mastoid bone with the landmarks in a deeper location. Simple mastoidectomy was carried out without drilling over the linea temporalis inferior (LTI) on 20 adult temporal bones. The suprameatal spine, i.e., Henle spine (HS), variants were noted. Morphometric measurements were performed between these surgical landmarks, and their variations with pneumatization or HS types were evaluated. Three types of HS were identified: triangular, crest, absent. The HS-lateral semicircular canal distance was 15 mm on average and longer in bones with a triangular HS than a crest type HS (16.4 vs. 14.3 mm). The LTI was found to be located on average 4.7 mm inferior to the middle fossa dural plate (MFD). The LTI-MFD distance had a tendency to be longer in bones without an HS than with a crest type of HS (5.9 vs. 3.9 mm). Chorda tympani emerged from the facial nerve at the stylomastoid foramen in five specimens (25%). This anatomical organization was not correlated with the type of HS. Korner's septum (KS) was identified in nine bones (45%). It was present in eight of 16 (50%) bones with good pneumatization. No tendency for the existence of KS was found for any specific type of HS. This study confirms that the mastoid antrum is located 15 mm deep to the lateral surface of the mastoid bone. It should be expected to be longer in bones with a triangular HS. In addition, the MFD is located on average 5 mm above the LTI, which could be useful information for beginners or inexperienced surgeons. The ear surgeon should anticipate that the MFD might be longer in bones without an HS.

Limbal relaxing incisions for primary mixed astigmatism and mixed astigmatism after cataract surgery.

PURPOSE: To evaluate the effect of limbal relaxing incisions (LRIs) in the treatment of primary mixed astigmatism and mixed astigmatism after cataract surgery. SETTING: Department of Ophthalmology, Inönü University, Malatya, Turkey. METHODS: Limbal relaxing incisions were performed to correct astigmatism in 37 eyes of 26 patients with mixed astigmatism. Twenty-four eyes had primary astigmatism, and 13 eyes had astigmatism after cataract surgery. The length, number, and depth of the incisions were determined using the Gills and Gayton nomogram. The manifest refractive astigmatism was measured preoperatively and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. Surgically induced astigmatism using the vector method, preoperative and postoperative uncorrected visual acuity (UCVA), and best spectacle-corrected visual acuity (BSCVA) were evaluated. Follow-up was at least 6 months in all cases. RESULTS: The mean preoperative and postoperative refractive astigmatism was 3.31 diopters (D) +/- 1.50 (SD) and 1.59 +/- 1.28 D, respectively (P <.001). The mean absolute change in refractive astigmatism was 1.72 +/- 0.81 D. No patient lost lines of UCVA or BSCVA. The safety index was 1.21 and the efficacy index, 0.88. The mean preoperative and postoperative UCVA was 0.29 +/- 0.22 and 0.54 +/- 0.31, respectively (P =.0001) and the mean BSCVA, 0.61 +/- 0.30 and 0.74 +/- 0.30, respectively (P =.0001). The mean vectorial magnitude was 2.32 +/- 1.36 D at the last follow-up. There were no serious postoperative complications. CONCLUSION: Limbal relaxing incisions are a simple, safe, and effective method to correct primary mixed astigmatism and mixed astigmatism after cataract surgery.

Radiologic anatomy of the sphenoid sinus for intranasal surgery.

Endoscopic surgery of the sphenoid sinus can present the operator with a considerable challenge. The relationship of the sphenoid sinuses, in particular on the lateral wall, to the carotid artery, optic nerve, as well as the other anatomic structures, is of utmost importance. Surgical complications can occur because of a lack of orientation during dissection. To avoid the complications or lessen, somehow, the rate of complications, some described the technique consisting of the opening of the sphenoid sinus ostium medially. We studied 69 axial high resolution computed tomography (HRCT) of temporal bones to reveal the relationship of sphenoid sinus to the vital structures and to get some measurements in the sphenoid sinus. The lateral distance from the sphenoid ostium revealed that the lateral distance was about the distance between both ostea. We consider that in selected cases the dissection might be carried out laterally from the sphenoid ostium for safe enlargement of the ostium and approaching the sinus.

Organized hematoma of the maxillary sinus mimicking tumor.

The authors present two cases of organized hematoma of the maxillary sinus. Both patients showed no bleeding abnormalities. Clinical symptoms, signs and radiologic appearance of the mass mimicked tumor during the initial diagnosis of the disease. To our knowledge, this is the first article describing organized hematoma in the maxillary sinus mimicking tumor without bleeding history and disorders. A provisional diagnosis of organized hematoma should be considered when a patient with history of epistaxis develops a slow-growing mass of the cheek and/or nasal obstruction.

Tympanic membrane and middle ear pathologic correlates in mucoid otitis media.

OBJECTIVE: The goal of this study was to correlate tympanic membrane (TM) and middle ear (ME) pathologies in mucoid otitis media (MOM). METHODS AND MATERIAL: Forty ears with MOM and 56 control ears were retrospectively evaluated for TM and ME pathologies. Comparisons of TM thicknesses in MOM versus control ears were correlated with the Student t test; chi(2) analysis was used to correlate pathologic findings of the TM and ME. RESULTS: Thicknesses in all quadrants except the umbo were increased in MOM because of infiltration of inflammatory cells and fibrosis. The most common ME pathologies were granulation tissue and fibrosis. Significant correlations included (1) TM retraction and ME granulation tissue and fibrosis and (2) pars flaccida, posterosuperior, and anteroinferior thickness and ME granulation tissue and fibrosis. CONCLUSION: TM changes are likely to occur in patients with otitis media with effusion (MOM), and their presence is a strong indication of underlying ME pathology.

Facial neuroma in the internal auditory canal.

Authors presented two cases of facial neuromas in the internal auditory canal, one without facial palsy and the other with facial palsy. In both cases neuromas were occult and undiagnosed. Although in the first case neuroma was greater than the other, facial palsy was not developed. The mechanism of the facial palsy due to neuromas could not be clearly clarified.

Congenital malformations of middle and inner ears of parabiotic twins.

We describe herein the congenital malformations of the middle and inner ears in temporal bones of parabiotic, monozygotic twins. Temporal bones were removed from twin B, who had no fetal cardiac activity and was born dead at 23-4/7 weeks, and twin A, the donor or "pump" twin in intrauterine life, who died shortly after birth at 20-6/7 weeks. The temporal bones were processed routinely in celoidin, stained with hematoxylin and eosin, and examined by light microscopy. We found that twin B had Mondini's dysplasia with associated deformities of the middle ear and in general showed more developmental anomalies than twin A, and we conclude that Mondini's dysplasia with anomalies of the middle ear may occur in the parabiotic twin syndrome, and the abnormalities may be explainable as the result of vascular disturbance, which also causes other lesions in these unusual cases.

Histopathologic features of the temporal bone in patients with cystic fibrosis.

OBJECTIVES: To investigate the lower than expected incidence of otitis media in patients with cystic fibrosis (CF) through histopathologic evaluation of temporal bones and to document pathologic findings in the inner ears of patients with CF who received long-term administration of antibacterial and diuretic agents. DESIGN: Clinical records of patients who died of CF were reviewed. Their temporal bones were sectioned, stained with hematoxylin-eosin, and examined histologically. Additional sections were stained with Alcian blue and periodic acid-Schiff for comparison of goblet cell densities from middle ears and auditory tubes of patients with CF with those of control temporal bones. Results were analyzed using the t test. SUBJECTS: Twenty-one temporal bones from 11 patients with CF and 13 bones from 8 age-matched patients without CF were selected. RESULTS: All temporal bones with CF had well-pneumatized mastoids. Temporal bones from 2 patients (3 ears) revealed histological findings of chronic otitis media with effusion. There was a statistically significant reduction in the density of goblet cells in the medial (P = .002) and lateral (P = .05) walls in patients with CF who had no otitis media histologically compared with control temporal bones. Two patients with CF who had otitis media had increased densities of goblet cells. Inner ear damage, due to ototoxic drugs, was seen in most of the temporal bones from patients with CF. CONCLUSION: Low densities of goblet cells in temporal bones with CF may contribute reduced amounts of viscous mucus, which can lead to a low incidence of otitis media.

Endoscopic dacryocystorhinostomy without stents.

OBJECTIVE: The aim of this study is to present our endoscopic DCR operation method without the use of silicone tubing and our results on the patients suffering from chronic epiphora with postsaccal stenosis. METHODS: Endoscopic dacryocystorhinostomy operations were performed to 21 sides of 18 patients who had chronic epiphora. No silicone tubing was used in any of the cases. In the postoperative healing period, the rhinostomy opening was maintained with frequent removal of nasal debris and using eyedrops. The patients were evaluated by fluoresceine test and endoscopic controls. RESULTS: Symptomatic improvement was achieved in 19 out of 21 sides of the patients (90.5%) and the results were confirmed by the fluoresceine test under endoscopic control. CONCLUSION: Our results of 21 sides of 18 cases underwent primary DCR without stents are as successful as those reported in the literature and the technique seems to be promising.

Intramuscular hemangioma of the masseter muscle.

Intramuscular hemangiomas (IMH) are uncommon tumors of the head and neck, but often occur in the trunk and extremities. When present in the head, the masseter muscle is the most frequently involved site, although constituting only 0.8% of all hemangiomas. Accurate preoperative diagnosis is uncommon without cytology or biopsy. A case of IMH of the masseter muscle in a 24-year-old Turkish woman is presented. Clinical, radiologic and histologic findings and treatment modalities are reviewed.

Benign fibrous histiocytoma of the nasal septum.

Among the non-epithelial tumours of the nasal cavity, paranasal sinuses and nasopharynx, fibrous histiocytoma is rarely encountered. A 45 year-old male patient complaining about nasal obstruction and nasal swelling was seen in the hospital ENT department. On examination, there was a mass located on the right anterior part of the nasal septum, about 2 x 1 x 1 cm in size. The pathologic diagnosis was benign fibrous histiocytoma. In this article we discuss the clinical, radiological, histopathological characteristics of fibrous histiocytoma and its differential diagnosis.

Middle ear pathology in day-care centre children.

BACKGROUND: Middle ear pathology, either otitis media with effusion or tubal dysfunction, is frequently seen in day-care centre children. Recognition and early treatment of this condition is crucial to the prevention of chronic otitis media, which is a major cause of hearing loss in later life. OBJECTIVES: We aimed to reveal the incidence of silent otitis media in day-care centre children and to determine the predisposing factors, risk factors and the awareness of the parents of the middle ear disease of their children. METHOD: Two hundred and thirteen children, aged 3-6 years, were screened in four daycare centres. A questionnaire was prepared that would reveal the predisposing factors. Information was gathered from both the parents and teachers. Children were examined by otoscopy, pneumotoscopy, tympanometry and X-rays for sinus pathology. RESULTS: Forty-three of 213 children had middle ear pathology; 39 of them were confirmed by tympanometry; 56.1 % of children had some degree of sinus pathology. We revealed that, although most of the children do not have the risk factors, they develop middle ear pathology. Among the parents, 81.4% of them were unaware of the condition. CONCLUSION: Early diagnosis of middle ear pathologies is necessary for prevention of future complications. In early stages the condition is silent. We emphasize the importance of the primary care physician's role in diagnosing the early stages of middle ear pathologies and recommend that teaching of otoscopic and pneumotoscopic skills should be part of the training for family physicians.