Detecting coagulability status by thromboelastography in women with the history of preeclampsia and inherited thrombophilia.

OBJECTIVE: To assign tendency to thrombosis in patients with preeclampsia and inherited thrombophilia using thromboelastography (TEG), and therefore to evaluate possible relationship between thrombophilia and preeclampsia. MATERIALS AND METHODS: Kinetics of clot formation was assessed with TEG analyzer in 49 patients with severe preeclampsia, 54 cases with previous diagnosis of inherited thrombophilia, and 31 controls. RESULTS: 'r, 'k', TMA, coagulation index (CI) parameters were found statistically discrete between patients with inherited thrombophilia and controls. The difference between preeclampsia and control groups was not statistically significant. The difference in a angle was statistically significant between thrombophilics and preeclamptics (p = 0.01), and between thrombophilics and controls (p = 0.004). CI was found statistically lower in thrombophilia group than control group (p = 0.006). Particularly, clot lysis time (CLT) was measured to shorten in preeclampsia when compared with controls and patients with thrombophilia (p = 0.032, p = 0.028, respectively). CONCLUSIONS: Not only the inherited thrombophilia group but also preeclampsia group demonstrated elongated clot initiation patterns when compared to the controls. Moreover, apart from the patients with inherited thrombophilia, preeclamptics exposed shorter CLT values indicating a possible increment in clot turn over, which eventually results in increased depletion of coagulation substrates, and thus, increased frequencies of oxidative cycle injury.

The prediction of para-aortic lymph node metastasis in endometrioid adenocarcinoma of endometrium.

The aim of this study was to assess factors associated with para-aortic lymph node metastasis in endometrioid adenocarcinoma. The data of 157 patients with endometrioid adenocancer, who underwent staging surgery, was reviewed retrospectively. A total of 23 patients (14.6%) had pelvic and 19 patients (12.1%) had para-aortic lymph node metastasis; 21% (4/19) of the patients with para-aortic lymph node involvement did not have pelvic lymph node metastasis. Para-aortic lymph node involvement was significantly more common in the presence of LVSI and pelvic lymph node metastasis, and pelvic lymph node metastasis was the only independent risk factor for para-aortic lymph node involvement. The sensitivity and NPV of positive pelvic lymph node in the prediction of para-aortic lymph node metastasis were found to be 78.9% and 97%, respectively. The corresponding rates for obturator and/or external iliac lymph node were 63.1% and 95%, respectively. In conclusion, although pelvic lymph node metastasis is the only independent risk factor for para-aortic lymph node involvement, negative pelvic lymph node is not enough to omit para-aortic lymph node dissection. On the other hand, intraoperative frozen section examination of obturator and/or external iliac lymph node to omit para-aortic lymphadenectomy might be a good option for the patients who have high medical risks for surgery.

Does the estradiol level on the day of human chorionic gonadotropin administration predict the clinical outcome of controlled ovarian hyperstimulation?

OBJECTIVE: To investigate the effect of serum estradiol (E2) levels on the day of human chorionic gonadotropin (hCG) administration on the outcome of controlled ovarian hyperstimulation (COH) in both long gonadotropin-releasing hormone (GnRH) agonist and GnRH antagonist protocols. MATERIALS AND METHODS: This study included 212 in vitro fertilization-embryo transfer (IVF-ET) cycles performed with either long GnRH agonist or GnRH antagonist protocols were classified into three groups according to serum E2 levels measured on the day of hCG injection: < 2,000 pg/ml, 2,000-4,000 pg/ml, and > 4,000 pg/ml. The three groups were compared according to age, number of retrieved oocytes, number of transferred embryos, and pregnancy rates for each of the stimulation protocols. RESULTS: The long and antagonist protocols were performed in 130 and 82 cycles, respectively. The pregnancy rates were 21.5% (28/130) and 23.2% (19/82) in the long- and antagonist-protocol groups, respectively. Serum E2 levels were measured on the day of hCG administration as < 2,000 pg/ml in 65 cycles, 2,000-4,000 pg/ml in 76 cycles, and > 4,000 pg/ml in 71 cycles. The number of retrieved oocytes increased in parallel to serum E2 levels (p = 0.001). However, there was no significant difference among groups in the pregnancy rates (p = 0.116). Similarly, the number of retrieved oocytes increased in parallel to serum E2 levels in both of the protocol groups (p value was 0.001 in both long GnRH agonist and antagonist protocols), but there was no correlation between the pregnancy rates and serum E2 levels (p value of long GnRH agonist protocol was 0.254 and thep value of antagonist group was 0.349). CONCLUSION: The serum E2 level on the day of hCG administration does not predict the pregnancy outcome in IVF with either long GnRH agonist or GnRH antagonist protocols.

Arterial vascularization patterns of the splenium: An anatomical study.

The aim of this study was to provide detailed information about the arterial vascularization of the splenium of the corpus callosum (CC). The splenium is unique in that it is part of the largest commissural tract in the brain and a region in which pathologies are seen frequently. An exact description of the arterial vascularization of this part of the CC remains under debate. Thirty adult human brains (60 hemispheres) were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. Then, the brains were fixed in formaldehyde, and dissections were performed using a surgical microscope. The diameter of the arterial branches supplying the splenium of the CC at their origin was investigated, and the vascularization patterns of these branches were observed. Vascular supply to the splenium was provided by the anterior pericallosal artery (40%) from the anterior circulation and by the posterior pericallosal artery (88%) and posterior accessory pericallosal artery (50%) from the posterior circulation. The vascularization pattern of the splenium differs in each hemisphere and is usually supplied by multiple branches. The arterial vascularization of the splenium of the CC was studied comprehensively considering the ongoing debate and the inadequacy of the studies on this issue currently available in the literature. This anatomical knowledge is essential during the treatment of pathologies in this region and especially for splenial arteriovenous malformations.

A short postgraduate anatomy course may improve the junior surgical residents' anatomy knowledge for the nerves of the inguinal region.

BACKGROUND AND AIM: Inguinal hernia repair is one of the most common operations in a junior surgical resident's postgraduate training. Short recall courses can improve junior residents' anatomy knowledge and results in better surgical outcomes. We aimed to investigate the effect of a short course on anatomical competency during inguinal hernia repairs. METHODS: During the first 25 inguinal hernia repairs, two junior residents were asked to identify iliohypogastric, ilioinguinal, and genital branch of genitofemoral nerves. Then, the residents were given a short recall course by anatomists. Afterwards, the participants were taken into an in-vivo anatomy test again. The same parameters were recorded in another 25 inguinal hernia repairs. In addition to the nerve identification records, case characteristics [body mass index (BMI < or = 25 vs. >25), hernia type (indirect vs. direct), and anesthesia used (general or regional vs. local)] were recorded. RESULTS: Anatomy education had a clear impact on the correct identification rates for the iliohypogastric and ilioinguinal nerves. The rates increased from 70% to 90% and above. Correct identification rate for the three nerves together significantly increased from 16 to 52% following anatomy education (P = 0.006). All three nerves were identified with significantly higher success rates after anatomy education. The increase in the success rate for identification of the genital branch of genitofemoral nerve was 4-fold. CONCLUSIONS: Short anatomy courses in specific subjects for junior surgical residents given by formal anatomists may be effective during postgraduate education. The benefit obtained in the present study for the inguinal region nerves may be expanded to more important anatomical structures, such as the recurrent laryngeal nerve in a thyroidectomy, or more complex subjects.

Arterial vascularisation of the anterior perforated substance.

INTRODUCTION: The arteries of the anterior perforated substance (APS) are important due to their role in supplying blood to important internal structures such as the internal capsule, putamen and caudate nucleus. The purpose of this study was to investigate in detail the arteries of the APS. METHODS: The arteries of the APS were investigated in 60 cerebral hemispheres from 30 adult cadaveric brains. The internal carotid arteries were cannulated and perfused with coloured latex. The branches of the middle cerebral artery (MCA) penetrating the APS were investigated. These arteries, known as the lateral lenticulostriate arteries and originating from the M1 segment, early temporal and early frontal branches of the MCA, were recorded. RESULTS: The branches of the anterior choroidal artery, which reached the APS, were seen in all specimens. We found one to three branches that arose from the A2 segment of the anterior cerebral artery (ACA) to the APS in all hemispheres, and one to three branches that originated from the A1 segment of the ACA in 48 hemispheres. In addition, two accessory MCAs that originated from the A2 segment of the ACA were recorded as variations, and perforating branches to the APS were observed. CONCLUSION: Serious complications like motor deficits can occur as a result of injury to the arteries of the APS. Hence, neurosurgeons performing operations such as aneurysm or insular tumour surgeries must be aware of the importance of preserving these arteries.

Lateral approach to the ankle and distal leg.

Fractures of the distal tibia are usually high-energy injuries and are well known for their soft tissue complications after surgery. Various factors have been studied regarding the possibility of them reducing the incidence of such damage, including timing of surgery, staged surgery, fixation method, and surgical approach. Less invasive surgical techniques with vascularity preserving approaches were proposed as reasonable solutions to this problem. The aim of this study was to investigate the presence of minor vascular structures, which can be preserved during anterolateral approach, possibly contributing to the success of the approach. Lateral approach for the distal tibia was performed in 22 cadaver feet. The mean distance between the lateral malleolus and the superficial peroneal nerve was 12.2 cm. Two different vascular pedicles, from peroneal vessels to muscles of the anterior compartment, were 4.3 and 8.2 cm away from the lateral malleolus, respectively. We conclude that preserving greater vascularity was possible in the lateral approach for the distal tibia, placing the plate in a completely submuscular plane.

Neurovascular relationship between abducens nerve and anterior inferior cerebellar artery.

We aimed to study the neurovascular relationships between the anterior inferior cerebellar artery (AICA) and the abducens nerve to help determine the pathogenesis of abducens nerve palsy which can be caused by arterial compression. Twenty-two cadaveric brains (44 hemispheres) were investigated after injected of coloured latex in to the arterial system. The anterior inferior cerebellar artery originated as a single branch in 75%, duplicate in 22.7%, and triplicate in 2.3% of the hemispheres. Abducens nerves were located between the AICAs in all hemispheres when the AICA duplicated or triplicated. Additionally, we noted that the AICA or its main branches pierced the abducens nerve in five hemispheres (11.4%). The anatomy of the AICA and its relationship with the abducens nerve is very important for diagnosis and treatment.

Relationships of the sural nerve with the calcaneal tendon: an anatomical study with surgical and clinical implications.

The percutaneous repair of the calcaneal tendon (CT) places the sural nerve (SN) at high risk for injury up to 60%. The aim of our study, therefore, was to explore and describe the course of SN in relation to the CT and to provide an anatomical description of the area in which the SN resides in order to assist surgeons in avoiding iatrogenic injury during surgical procedures in the leg. Forty-four lower extremities of 22 adult cadavers were dissected and the course of the sural nerve investigated. The CT was divided into ten horizontal equal fractions. The widths of CT, and horizontal distances of the SN and small saphenous vein (SSV) to a vertical line connecting the midpoints of these fractions were measured. All the measurements were obtained using a computer-assisted image analysis system. In 95.5% of the specimens the sural nerve was medial to the lateral border of the CT proximally and was intersecting with the lateral border of the CT at the 55% of the mid-tendon line. The SN divided into its terminal branches at a mean of 90% of the mid-tendon line. Based on our results, the course of the sural nerve is quite variable and seems to have the highest risk of injury at its proximal portion. The sutures placed on the CT distal to the 55% of the mid-tendon line may decrease iatrogenic nerve injury.

Callosal branches of the anterior cerebral artery: an anatomical report.

Although the morphology of the corpus callosum is well defined, the arterial supply of this structure has not been comprehensively studied. To elucidate this further, 40 cerebral hemispheres from 30 adult cadaveric brains were obtained. The anterior cerebral arteries were cannulated and injected with red latex. The following were observed and documented: (1) the number, diameter, and course of the arteries supplying the corpus callosum; (2) the territories vascularized by these arteries; (3) any variations of the callosal arteries. Short callosal arteries were present in 58 hemispheres (96.6%) and supplied the superficial surface of the corpus callosum along its midline and were a primary arterial source to this structure. Long callosal arteries were found in 28 hemispheres (46.6%) and contributed to the pial plexus. The cingulocallosal arteries were present in all hemispheres and supplied the corpus callosum, cingulate gyrus, and also contributed to the pericallosal pial plexus. The recurrent cingulocallosal arteries were present in 17 hemispheres (28.3%) and also contributed to the pericallosal pial plexus. The median callosal artery, an anatomical variation, was present in 10 brains (33.3%). This vessel supplied the corpus callosum and the cingulate gyrus. The aim of the present study was to provide a detailed description of the arteries supplying the corpus callosum for those who encounter these vessels radiologically or surgically.

The innervation of patella: anatomical and clinical study.

As much interest has been focused on afferent innervation of knee than that of patella, there are few articles about patellar innervation. But in clinical practice anterior knee pain due to patellar disorders is a quite frequent problem. Our aim was to review the innervation pattern of patella and to give the topographic anatomy of the nerves. We dissected 30 knees of 15 formaldehyde-fixed cadavers. Two nerves from vastus medialis and lateralis were found to reach patellar edge. Apart from these, we were unable to find any other neural structures around patellae. Mean distances between the tuberosity of the tibia and medial and lateral nerve entry points were 90.1(range 74-102) and 96.3 mm (range 76-109), respectively. The angles between lines which join the entry points of nerves and vertical line to the center point of patella were measured in frontal plane. It was approximately 60 degrees medially and 40 degrees laterally. To confirm that these nerves are patellar pain afferents, we performed a local anesthesia test in 32 knees of 20 patients with patellofemoral pain. Clinically, there was a significant difference between the visual analogue scale (VAS) scores before and after local anesthetic injections (p<0.01). Previous studies have emphasized especially the medial innervation. We found that both superomedial and superolateral nerves were important for patellar innervation. We described precisely the entry points of these nerves to patella for selective denervation.

The origin and relations of the anterior choroidal artery: an anatomical study.

There has recently been an increase in surgical interventions to the inferior temporal lobe. The aim of the present study is to examine the anatomical structure and relations of the anterior choroidal artery, which extends to this region. A mixture of latex and ink was injected into the internal carotid and basilar arteries of 15 brains from fresh cadavers. In 18 out of 30 cases (60%) the anterior choroidal artery arose from the posteroinferior aspect of the internal carotid artery, in 8 (22.2%) from the posterolateral aspect and in 4 (2%) from its anterior part. The diameter of the anterior choroidal artery was 0.94 mm on average (0.7-1.2) and the average distance from the posterior communicating artery was 5.3 mm (3.8-8 mm); its distance to the bifurcation of the carotid was found to be 4.0 mm on average (2.2-8 mm). The cisternal segment of the anterior choroidal artery and the optic tract formed a neurovascular bundle. The branches arising from the plexal segment supply the lateral geniculate body, the thalamus and the optic tract. The resulting knowledge of the neurovascular relations of the anterior choroidal artery provides a safe surgical approach to the inferior temporal lobe.

Evaluation of the anterior and posterior ethmoidal canal by computed tomography.

AIM: To examine the anatomy, length and angulation of the anterior and posterior ethmoidal canals (AECs and PECs) using computed tomography (CT), and to determine the anatomical landmarks in which the canals are expected to be seen in transverse and coronal planes. MATERIALS AND METHODS: CT images of 150 patients were analysed. One, 2, and 3 mm thick sections were obtained separately in axial and coronal images. The frequency of visualization of the AECs and PECs, and if present, a third canal, was noted. The course and the angulation of the AEC and the PEC in transverse and coronal planes were recorded. On axial sections the distance between the AEC and PEC and the previously defined landmarks were measured. On coronal images, the distances were calculated from the thickness of the cross-section and the number of sections between the various structures. RESULTS: The AEC was identified as a separate canal in 84% of patients, and was embedded in the ethmoid roof in 16%. The PEC was seen as a separate canal in 8% and was present in the ethmoid roof in 92%. On the 1 mm thick coronal and transverse sections, a third canal was identified at the junction of the middle and posterior third of the AEC-PEC distance in both of the images. The average lengths of these canals were 4-12 mm (mean 8.2 mm) for the AEC, and 2-13 mm (mean 7.6 mm) for the PEC. CONCLUSIONS: To avoid the complications that can develop during endoscopic sinus surgery; the course, length and the angulations of the anterior and posterior ethmoidal arteries and their canals can be identified by CT in standard positions if a sufficiently thin section thickness is used. The present study has shown the exact CT localization of the AECs and PECS, which are frequently overlooked when evaluating para-nasal sinuses.

Should asymptomatic bacteriuria be screened in pregnancy?

The incidence of asymptomatic bacteriuria is reported as 2-14% during pregnancy. Fetal and maternal complications like acute pyelonephritis, hypertension, anemia, preterm labor, low-birth-weight infants and intrauterine growth retardation can be expected. The purpose of this study was to determine the incidence of asymptomatic bacteriuria during pregnancy and its relation to pregnancy complications. The study involved 270 pregnant women up to 32 gestational weeks during a 9-month period. At the initial visit, they were screened with urine culture in order to detect asymptomatic bacteriuria. A control group was formed in a retrospective manner from the first day of the study with 186 pregnant women who delivered in our clinic and who were not screened for asymptomatic bacteriuria. The incidence of asymptomatic bacteriuria was 9.31%. Escherichia coli accounted for 79%, which was the most frequent of the isolates. We observed recurrence and had to apply treatment again to 21.7% of the women. The sensitivity, specificity, positive predictive and negative predictive values of leucocyturia as a screening test for asymptomatic bacteriuria were 91.3%, 83.6%, 45.6% and 98.5%, respectively. We diagnosed preterm labor in six of 23 (26%) with asymptomatic bacteriuria and 16 in 163 (9.3%) women in the urine culture negative group. The ratio acute pyelonephritis in the group which was routinely screened and treated for asymtomatic bacteriuria was 0.5% while the prevalence was 2.1% in the nonscreened group. Considering the relatively high incidence of asymptomatic bacteriuria during pregnancy and the relevant complications, we propose to screen and treat asymptomatic bacteriuria routinely in all pregnant women.

Plasma ascorbic acid level and erythrocyte fragility in preeclampsia and eclampsia.

An imbalance between oxidants and antioxidants in the circulation is blamed to cause preeclampsia and eclampsia. In this study plasma ascorbic acid level was analysed in 13 eclamptic, 14 mild preeclamptic, 12 severe preeclamptic and 20 uncomplicated pregnancies to see whether there is any correlation with blood pressure, proteinuria, serum triglyceride level, erythrocyte fragility and leukocyte count. Plasma ascorbic acid level was normal and had no significant difference among the groups. Fasting serum triglyceride level was significantly higher in the study group than in the control group but it did not differ among the three study groups. Erythrocyte fragility was found to be increased in all three study groups. Blood leukocyte count was increased in the study groups, especially in the eclampsia group. However, plasma ascorbic acid level and erythrocyte fragility were found to have no significant correlation with blood pressure and proteinuria. It was concluded that though the ascorbic acid levels were normal in both the study and the control groups, erythrocyte fragility increased probably due to an elevation in peroxide and free radical levels in preeclampsia and eclampsia groups, but without any correlation with the severity of the clinical picture.