Endobronchial Ultrasonography to Assess and Evaluate Tracheobronchial Tree Invasion in cT4b Esophageal Cancer Patients Treated with Definitive Chemoradiotherapy: Assessment of Resectability.

BACKGROUND: In cT4b esophageal cancer, accurate assessment of tracheobronchial tree invasion after definitive chemoradiotherapy (dCRT) aids in the selection of patients for whom an oncologic radical esophagectomy can be achieved. The current report aimed to determine the accuracy of endobronchial ultrasound in assessing tumor invasion in the tracheobronchial tree after dCRT in patients with cT4b esophageal cancer. METHODS: Esophageal cancer patients with suspicion of tracheobronchial tree invasion on the diagnostic contrast-enhanced computed tomography (CT) who underwent a staging endobronchial ultrasonography (EBUS) were eligible for inclusion in this study. To assess the accuracy of the EBUS in assessing tumor ingrowth in the tracheobronchial tree after dCRT, patients who had an EBUS during restaging and underwent surgery were included in the final analysis. RESULTS: The final analysis included 26 patients. For 18 (90%) of 20 patients in whom the anatomy of the tracheobronchial tree was restored on the restaging EBUS and tumor invasion was considered to be absent, a radical esophagectomy was achieved. In six patients, persistent ingrowth was observed during the restaging EBUS. For these patients, the EBUS was repeated after a median of 9 weeks. Tumor invasion was considered to be absent in four patients, and a radical resection was achieved in three of these patients. CONCLUSION: The EBUS provides valuable information on the assessment of tracheobronchial tree invasion in cT4b esophageal cancer patients after dCRT. This information could aid in the proper selection of patients who benefit from a curative but highly invasive esophagectomy.

High Anxiety Levels before Elective Cesarean Section Can Negatively Affect the Mother and Fetus.

BACKGROUND: Both pregnancy and surgery cause anxiety. This situation may negatively affect the health of the mother and baby. AIM: The effect of anxiety level before cesarean section (CS) on feto-maternal outcomes was investigated. METHODS: The preoperative anxiety score was determined with the State-Trait Anxiety Inventory (STAI) in 224 pregnant women who were planned for elective CS. RESULTS: Among patients, 33.5% were in the low anxiety group, 27.2% in the moderate, and 39.3% in the high anxiety group. The average birth weight in the low anxiety group was noticeably higher than that of the high anxiety group (P = 0.018). The mean heart rate at postop 1st and 24th hour in the high anxiety group was higher than the moderate anxiety group (P < 0.028). In addition, diastolic blood pressure (DBP) at the sixth hour in the low anxiety group was found to be lower than in the moderate anxiety group (P < 0.05). CONCLUSION: According to these results, it was found that an increased anxiety score before CS is associated with low birth weight in the baby, higher heart rate, and DBP in the mother.

Salvage Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) for T4b Esophageal Cancer After Definitive Chemoradiotherapy.

BACKGROUND: Patients  with esophageal cancer  that invades adjacent structures (cT4b) are precluded from surgery and usually treated with definitive chemoradiotherapy (dCRT). dCRT might result in sufficient downstaging to enable a radical resection, possibly improving survival. This study aimed to assess the perioperative and oncologic outcomes of a salvage robot-assisted minimally invasive esophagectomy (RAMIE) in patients with cT4b esophageal cancer after dCRT. METHODS: Between June 2012 and November 2019, patients who underwent a RAMIE with a gastric conduit reconstruction after completion of dCRT for cT4b esophageal carcinoma were identified from a prospectively maintained surgical database at the University Medical Center Utrecht. RESULTS: In total, 24 patients with a histopathologically confirmed T4b adenocarcinoma or squamous cell carcinoma of the esophagus were included. The adjacent organs involved were the tracheobronchial tree (67%), aorta (21%) or both (13%). No conversions or major intraoperative complications were observed. A radical resection was achieved in 22 patients (92%), and a pathologic complete response was observed in 13 (54%) patients. Postoperative grade 2 or higher complications occurred in 20 patients (83%). The disease-free survival at 24 months was 68% for the patients in whom a radical resection was achieved. CONCLUSION: In patients with cT4b esophageal cancer treated with dCRT followed by a salvage RAMIE, a radical resection rate of 92% was achieved, with acceptable complications and promising survival rates. These results demonstrate the feasibility of a curative surgical treatment for patients with initially irresectable esophageal cancer but underscore the importance of a proper preoperative patient selection.

Can Intra-articular 1α, 25-Dihydroxyvitamin D3 Administration Be Therapeutical in Joint Cartilage Damage?

INTRODUCTION Vitamin D-deficiency is known to cause nerve conduction impairments, cancer and chronic diseases, as well as the pathogenesis of osteoarthritis. Our goal with this study is to evaluate the cartilage healing by applying intraarticular 1α, 25 (OH) 2D3 at different doses in rats with normal vitamin D levels and metabolism, which we made focal chondral damage model in the knee joint. MATERIAL AND METHODS 35 male Sprague-Dawley rats aged 20-24 weeks were used in our study. Both knees of rats were cartilage defected surgically on day 0. Joint injections performed at 06:00 am on 0th and 2nd days and after second injection others performed on days 9-16 and 23 following a weekly period. RESULTS In the fourth week, hematoxylin eosin staining measurements showed statistically significant difference according to the groups (p < 0.01) Metalloproteinase-13 (MMP-13) in histological staining for evaluating cartilage healing and healing levels showed statistically significant differences between the groups at first week and fourth week (p < 0.05). DISCUSSION Vitamin D, which affects many tissues through its receptors, is believed to be chondroprotective and neuroprotective by decreasing the expression of MMP in cartilage fibroblast, macrophage, lymphocyte through its intracellular receptors. To the best of our knowledge, this is the first study known to be intraarticular use of 1α, 25-dihydroxyvitamin D3. Our study has been found to be safe and successful in terms of weight, systemic PTH and 1α, 25-dihydroxyvitamin D3 levels in rats during treatment as well as better healing of cartilage damage. Key words: vitamin D3 receptor, articular cartilage, orthopedics, nerve conduction.

Pulmonary diffusion capacity predicts major complications after esophagectomy for patients with esophageal cancer.

A reduced forced expiratory volume in one second (FEV1) is a well-recognized risk factor for complications after esophagectomy. Lung diffusing capacity for carbon monoxide (DLCO) is not routinely integrated in the risk assessment of esophagectomy. The aim of this study is to evaluate the association of preoperative pulmonary function tests with major postoperative complications after esophagectomy for cancer. In order to achieve this aim, 459 patients with newly diagnosed esophageal cancer who underwent elective transthoracic (n = 352) or transhiatal (n = 107) surgical resection of the esophagus with cervical anastomosis between 2003 and 2015 were analyzed. Multivariable logistic regression analysis was performed to assess the association of preoperative pulmonary function tests (expressed as % of predicted) with major complications after esophagectomy, adjusted for previously identified predictors. Major complications were defined as Clavien-Dindo grade IIIb or higher. Of the 459 included patients, 114 (24.8%) developed major complications. In univariable analysis FEV1, forced vital capacity (FVC), vital capacity (VC), and DLCO were associated with major complications. After adjusting each pulmonary function test for age, American Society of Anesthesiologists (ASA) score, cardiac comorbidity, diabetes mellitus, peripheral vascular disease, and surgical approach, FVC (OR: 1.24 per 10% decrease; 95% CI: 1.06-1.45; P = 0.004), VC (OR: 1.19 per 10% decrease; 95% CI: 1.02-1.39; P = 0.025) and DLCO (OR: 1.16 per 10% decrease; 95%CI: 1.02-1.33; P = 0.025) remained predictive factors for major surgical complications. In multivariable analysis in which all pulmonary functions tests were combined, DLCO was the strongest predictor of major complications (OR: 1.14 per 10% increase; 95% CI: 1.01-1.30; P = 0.046). The ideal cut-off for DLCO% of predicted was determined at <84% (OR: 1.97; 95% CI: 1.28-3.03; P = 0.002). These data indicate that DLCO is an independent predictor of major complications after esophagectomy for cancer. This pulmonary function test deserves greater consideration in prediction research of major complications after esophagectomy.

Is Intraarticular Antibiotic Administration Effective in the Treatment of Methicillin-Resistant Staphylococcus aureus?

PURPOSE OF THE STUDY Septic arthritis is an infection of joints caused by a pathogenic microorganism. Septic arthritis has a mortality rate of 11-40% when it's not treated properly. The mortality rate with methicillin-sensitive Staphylococcus aureus (MSSA)is 5-7%, while the rate with methicillin-resistant Staphylococcus aureus (MRSA)is 13-20%. The aim of this study is to evaluate the effects of intraarticular vancomycin and teicoplanin on joint cartilage in in vivo settings and its utility in routine MRSA treatment. MATERIALS AND METHODS In our study, 35 male Sprague-Dawley rats aged 28 days were used. Rats were obtained from the Regenerative and Restorative Medicine Research Center (REMER) of Istanbul Medipol University. Rats were randomly divided into 5 groups each containing 7 rats. Joint injections were administered with isoflurane analgesia every day at 6 am. Three rats (15 rats) from each group were sacrified in seventh day and evaluated immunohistologically to evaluate acute healing in articular cartilage. All remaining rats were sacrificed on day 28 and their knees were evaluated by immunohistochemical examination. RESULTS In our study, there were no complications in any rat during injection and the study period. Hematoxylin eosin (H & E) histological staining for evaluating cartilage healing and healing levels did not show statistically significant differences between the groups at first week (p > 0.05). Matrix metalloproteinase-13 (MMP-13) staining did not show any statistically significant difference between the groups. (p > 0.05). DISCUSSION MRSAseptic arthritis, diagnosed for the first time in 1960, has recently been responsible for 6-22% of all septic arthritis and is increasing day by day. The use of systemic vancomycin or teicoplanin is the first-line treatment method in MRSA septic arthritis. Serum levels reach the desired level, especially with intravenous infusion dose. On the other hand, it has been shown that intraarticular concentration does not reach a sufficient level in studies conducted. The use of intraarticular antibiotics during treatment can lead to more effective and early disease control by turning this negative situation into favor of the patient. As a result, intraarticular vancomycin and teicoplanin maximale tolerable and maintenance doses can be safely used beside surgery and intravenous antibiotics to increase efficacy of treatment, reduction of recurrence rates and reduction of mortality in MRSAseptic arthritis. CONCLUSIONS Intraarticular vancomycin and teicoplanin maximale tolerable and maintenance doses can be safely used beside surgery and intravenous antibiotics to increase efficacy of treatment, reduction of recurrence rates and reduction of mortality in MRSA septic arthritis. Key words:arthritis, infectious; methicillin-resistant Staphylococcus aureus; mortality.

Orthopedics and Traumatology Residency - Working Conditions, Training, and Psychological Stress.

PURPOSE OF THE STUDY The specialty of orthopedics and traumatology that is completed in the 5 years period in our country is a challenging educational process and our purpose in this study is to demonstrate through a survey training conditions of the orthopedic assistants in our country and the effects of this process on assistants. MATERIAL AND METHODS 524 (70.05%) of 748 assistants who receive specialization training in Turkey were reached. There were 20 multiple choice questions ( 1 mark each) and 3 questions (more than 1 mark each) in the survey consisting of twenty-three questions. Our study group was formed by doctors who have still worked as assistant in our country and have accepted to participate in the study. The doctors who finished assistantship with any reason and did assistantship for time less than 6 months and did not exactly fill the questionnaire form were excluded from the study. RESULTS 524 (71.97%) of 728 assistant who are in 40 (100%) of 40 provinces where assistant training given in Turkey were reached. 474 (90.45%) participants were satisfied to do orthopedic specialization. When considering working hours, it was observed that 337 (64.31%) participants had over 90 hours weekly including night shift and 521 (99.42%) participants had to work after night shift. The majority of participants (361 persons 68.89%) were receiving salaries between TL 4000-6000. When looking at the entire working group, the rate of participants who said that scientific training is weak or there is no scientific training was 427 (81.48%). CONCLUSIONS Our survey study is one of the first statistical study which investigating professional and social problems of orthopedic assistants. Some of important problems as training satisfaction, abuse by patients and/or manager, the average monthly income and psychological status assessment is emphasized. Orthopedics and Traumatology assistantship is a challenging process to cause physical and psychological problems with the hard working conditions in our Turkey. Key words:residency training, orthopedic surgery, life quality, salary.

Rapid on-site evaluation during endoscopic ultrasound-guided fine-needle aspiration of lymph nodes does not increase diagnostic yield: A randomized, multicenter trial.

OBJECTIVES: Studies on the impact of rapid on-site evaluation (ROSE) during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of lymph nodes are retrospective and have shown conflicting results. We aimed to compare the diagnostic yield of EUS-FNA of lymph nodes with ROSE (ROSE+) and without ROSE (ROSE-). METHODS: This was a multicenter, randomized controlled trial. Consecutive patients who were scheduled to undergo EUS-FNA of mediastinal or abdominal lymph nodes were randomized to ROSE+ or ROSE-. In the ROSE+ group, the number of passes was dictated by the on-site cytotechnician. In the ROSE- group, five passes were performed without interference from the cytotechnician. All samples were reviewed by a single-expert cytopathologist, blinded to group allocation. Primary endpoint was diagnostic yield with and without ROSE. RESULTS: After inclusion of 90 patients, interim analysis showed futility of study continuation since diagnostic yield of ROSE+ and ROSE- were comparable. A total of 91 patients were randomized to ROSE+ (N = 45) or ROSE- (N = 46). Diagnostic yield of ROSE+ and ROSE- and diagnostic accuracy were comparable: 93.3% vs. 95.7% (P = 0.68) and 97.6% vs. 93.2% (P = 0.62), respectively. Two major complications (one per group) occurred (p = 0.99). ROSE- patients more often reported self-limiting post-procedural pain (p < 0.001). Median procedure time for ROSE+ (20 min) and ROSE- (23 min) was comparable (P = 0.06). Median time to review slides in the ROSE- group (12:47 min) was longer than with ROSE+ (7:52 min) (P < 0.001). Mean costs of ROSE- and ROSE+ were comparable: €938.29 (±172.70) vs. €945.98 (±223.38) (P = 0.91), respectively. CONCLUSIONS: Diagnostic yield and accuracy of EUS-FNA of mediastinal and abdominal lymph nodes with and without ROSE are comparable. Time needed to review slides was shorter and post-procedural pain was less often reported in the ROSE+ group. Based on the primary outcome, the implementation of ROSE during EUS-FNA of mediastinal and abdominal lymph nodes cannot be advised. (Dutch Trial Register: NTR4876).

The Effect of Incorrect Foot Placement on the Accuracy of Radiographic Measurements of the Hallux Valgus and Inter-Metatarsal Angles for Treating Hallux Valgus.

PURPOSE OF THE STUDY Accurate radiographic measurements are crucial in treating hallux valgus (HV). This three-dimensional deformity should not be evaluated from one joint on one plane. However, in practice, surgeons measure the deformity only on transverse dorsoplantar radiographs. We determined the amount of error associated with positioning the foot incorrectly on radiographs. MATERIAL AND METHODS To simulate incorrect positions of the foot in radiographic evaluation, we designed an angled device that can move in transverse and frontal plane. In four patients with symptomatic HV, we took weight-bearing radiographs of the involved foot in seven different positions. These 28 radiographs were given identifying but meaningless labels. On each radiograph, six surgeons blinded to the position of the radiograph measured the HV angle (HVA) and the inter-metatarsal angle (IMA) and state the treatment plan according to five treatment options were given to participants. RESULTS Inter-observer agreement was high for measurements of HVA and IMA in all positions (interclass correlation coefficients, 0.96 and 0.88, respectively). However, intra-observer agreement was poor for HVA (intra-observer agreement, 0.17) but good for IMA (intra-observer agreement, 0.64). According to the measurements in different positions, intra-observer treatment choices revealed moderate results (ICC: 0.524). Clinical Relevance Radiographic measurements are very important on the treatment decisions of hallux valgus. The foot position can influence the measurement accuracy and can cause incorrect decisions. In this study, we evaluated the impact of foot positions on measurements of hallux valgus angle and inter-metatarsal angle. Additionally, we evaluated the incorrect foot positioning on treatment decisions. Moreover, we analyzed intra-observer and inter-observer agreements of these angles in various positions. CONCLUSIONS We recommend that measurements of IMA are more reliable than those of HVA for managing hallux valgus in terms of false weight bearing radiographs taken in different positions. Positional changes during foot radiographs could lead clinicians to perform incorrect HVA and IMA measurements. This could change the treatment option. HVA measurements were more affected with foot positioning. It is important to take full weight bearing foot radiographs in correct technique. Key words: hallux valgus, radiology, data accuracy.

Effect of Erbium:yttrium aluminum garnet laser on bond strength of a total-etch adhesive system to caries-affected dentin on gingival wall.

PURPOSE: To assess the effect of the erbium:yttrium aluminum garnet (Er:YAG) laser on bond strength of a total-etch adhesive system to the caries-affected dentin on the gingival wall. MATERIALS AND METHODS: Ten human molars with proximal carious lesions were randomly divided into two groups. In the first group, the carious dentin was removed with a bur, whereas in the second group it was removed with the Er:YAG laser. Carious lesions were excavated with one of these two techniques until laser fluorescence values decreased to 15 in the center of the lesions. The teeth were then restored with a total-etch adhesive system (Adper Single Bond 2) and composite resin (Filtek Z250). Five teeth from each group were sectioned to obtain 1 mm2 stick-shaped microtensile specimens from each tooth. Twenty-five specimens were obtained for each group with using this technique. The data were analyzed in independent-samples t-test (α = 0.05). For each removal technique, one sample was analyzed using scanning electron microscopy. RESULTS: No statistically significant differences were found between the bond strength of the Er:YAG laser and the bur-treated groups (P > 0.05). CONCLUSION: The Er:YAG laser treatment did not negatively affect the bonding performance of the total-etch adhesive system to caries-affected dentin on the gingival wall.