Assessing the binding interaction of polystyrene sulfonate with amitriptyline in healthy volunteers: a cross-over design - The BIND study.

PURPOSE: Polystyrene sulfonate is used for binding potassium in patients with chronic kidney disease (CKD). Because of its binding properties, it can potentially bind other medications and thereby decrease their bioavailability and effectiveness. Amitriptyline, often used by CKD patients for neuropathic pain, shows significant binding to polystyrene sulfonate in vitro. The purpose of this study was to determine the effect of polystyrene sulfonate on the exposure of amitriptyline in vivo when taken concomitantly in healthy volunteers. METHODS: We performed a prospective cross-over study in nine healthy volunteers. Participants were 18 years of age or older, did not use any medication, and had no known allergy to amitriptyline or polystyrene sulfonate. Participants visited Deventer Teaching Hospital twice. Once they received a single dose of amitriptyline 50 mg and once they received a single dose of both polystyrene sulfonate 15 g and amitriptyline 50 mg taken concomitantly, with a wash out period of at least 1 week. After intake of the medication, six blood samples were collected, at 2, 3, 4, 5, 6, and 8 h. Blood samples were analysed to determine maximum concentration (Cmax) and area under the curve 0-8 h after intake (AUC0-8 h). Difference in Cmax and AUC0-8 h was analysed with a paired T-test or Wilcoxon signed rank test, depending on normality of the data. A p-value < 0.05 was considered statistically significant. RESULTS: Of the nine participants included, eight participants completed both visits to the hospital. Mean maximum concentration (Cmax) of amitriptyline was 35.61 µg l-1 (95% CI 27.90-43.33 µg l-1) when taken alone, compared to 9.25 µg l-1 (95% CI 6.59-11.92 µg l-1) when taken with polystyrene sulfonate (p < 0.001). Mean AUC0-8 h of amitriptyline was 168.20 µg × h l-1 (95% CI 139.95-196.45 µg × h l-1) when taken alone and 45.78 µg × h l-1 (95% CI 30.20-61.36 µg × h l-1) when taken with polystyrene sulfonate (p < 0.0001). CONCLUSION: These results show a significant decrease in exposure of amitriptyline of approximately 75% when taken concomitantly with polystyrene sulfonate, thereby probably compromising therapy efficacy. Patients using both amitriptyline and polystyrene sulfonate should be informed to separate intake of these medications. TRIAL REGISTRATION: NL8539 (17 April 2020).

A serious complication of liver hydatid cysts in children: cystobiliary fistulas.

AIM: We aimed to determine predictive factors for predicting cystobiliary fistulas (CBF) in children after treatment of liver hydatid cyst (LHD). METHODS: The records of patients who were treated for LHD between 01.06.2009 and 1.06.2019 were retrospectively reviewed. Age, sex, laboratory test results, size and number of cysts, method of first intervention (percutaneous or surgery), whether or not CBF developed and how it was treated were investigated. Among findings, those could be predictive were investigated. Data were evaluated with SPSS 21.0 program, p < 0.05 was considered significant. RESULTS: Of the 97 patients, 48 (49.5%) were male, 49 (50.5%) female, the mean age was 11.2 years, Eighty patients had right (82.5%), 13 had left, and 4 had bilobar involvement. As first intervention, surgery was performed in 39 (40.2%); percutaneous treatment was performed in 58 (59.8%) patients. In 8 patients (20.5%) in surgery group and in 6 patients (10.3%) in percutaneous group, totally in 14 patients (14.4%), CBF developed. The mean cyst diameter of CBF-developed group was 114.36 mm, and of CBF-undeveloped group was 74.30 mm. There was no statistically significant differences between groups in terms of age, sex, involved lobe, other organ involvement, and preoperative results (p > 0.5). There was a significant relationship between the cyst diameter and the rate of CBF development in both surgical and percutaneous groups (p < 0.05). ROC analysis was performed, and the cut-off value for the development of CBF detected as 69 mm for children. Since obstructive jaundice seen in adults is not common in children, an increase in liver function tests and bilirubin levels were not seen in our patients. CONCLUSION: A significant correlation was found only between the size of the cyst and developing CBF. Cysts greater than 69 mm have a higher risk of developing CBF after both percutaneous and surgical treatment and should be closely monitored.

COMPARISON OF CARDIAC ARRHYTHMIA TYPES BETWEEN HYPERTHYROID PATIENTS WITH GRAVES' DISEASE AND TOXIC NODULAR GOITER.

PURPOSE: Previous studies have demonstrated the relationship between hyperthyroidism and increased risk of cardiac arrhythmias. The most common causes of hyperthyroidism are Graves' disease (GD) and toxic nodular goiter (TNG). The aim of our study was to demonstrate if the underlying mechanism of hyperthyroidism, in other words autoimmunity, has an impact on the type of cardiac arrhythmias accompanying hyperthyroidism. METHOD: Twenty patients with TNG and 16 patients with GD who had overt hyperthyroidism were included in the study. Age, sex, thyroid hormone levels, thyroid autoantibody positivity, thyroid ultrasonography and scintigraphy results were recorded. 24-hour Holter ECG monitoring was performed in all patients. RESULTS: Mean age was significantly higher in the TNG group compared to the GD group (62.9±11.5 vs. 48.9±8.6 years, p=0.001). Free T3 was significantly higher (7.87±3.90 vs. 5.21±1.53 pg/mL, p=0.033) in the GD group while free T4 and TSH levels were similar between the two groups. In 24-hour Holter ECG recordings nonsustained ventricular tachycardia (VT) rates were significantly higher in the GD group than in TNG group [18.75% (n=3/16) vs. 0% (n=0/20), respectively, (p=0.043)]. Paroxysmal atrial fibrillation (AF) rates were significantly higher in the TNG group compared to GD group [(30% (n=6/20) vs. 0% (n=0/16), respectively, (p=0.016)]. CONCLUSION: Although free T3 levels were lower, paroxysmal AF rates were found significantly higher in the TNG group which may be associated with significantly higher age of this group. On the other hand, higher rate of nonsustained VT in the GD group may be related to either significantly higher free T3 levels or autoimmunity.

3,3 diindolylmethane leads to apoptosis, decreases sperm quality, affects blood estradiol 17 ß and testosterone, oestrogen (α and ß) and androgen receptor levels in the reproductive system in male rats.

3,3 Diindolylmethane (DIM) is a major digestive product of indole-3 carbinol, obtained from Brassica family vegetables such as broccoli, cabbage and Brussels sprouts. This study aimed to investigate the effects of DIM on sperm parameters, histological structures of testicular tissues, blood testosterone (T) and estradiol 17-ß (E2) in male rats. Thirty-eight male Sprague Dawley rats were used. Rats were divided into four groups: Group I: referred as Control group, received corn oil only; Group II: as DIM-10, rats received 10 mg kg-1 DIM; Group III: as DIM-50, rats received 50 mg kg-1 DIM; Group IV: as DIM-100, received 100 mg kg-1 DIM during 53 days. Spermatological parameters, malondialdehyde (MDA) levels of testes and serum T and E2 levels were assayed. Histopathological examinations of tests were done. DIM caused an increase in MDA levels. It decreased motility and live sperm rates and increased degeneration of testicular tissues. While DIM-10 did not affect abnormal sperm rate, higher concentrations increased the abnormalities. Sperm density was higher in DIM-10 groups when compared to both other groups. Only DIM-50 had an anti-androgenic effect among all groups. Only, DIM-10 showed anti-estrogenic activity as compared to higher DIM groups. In conclusion, DIM (i) had side effect on some sperm characteristics, (ii) increased the MDA levels and (iii) led to histological degeneration of testicular tissues and apoptosis in a dose-dependent manner.

A Deletion Mutation of the Connexin 26 (Gjb2) Gene in a Turkish Patient with Vohwinkel Syndrome .

Vohwinkel syndrome (VS), also known as keratoderma hereditaria mutilans, is a rare keratinization genetic disorder characterized by palmoplantar keratoderma, skeletal dysmorphisms and varying degrees of sensorineural deafness. Its mode of inheritance is autosomal-dominant, with mutations in loricrin and connexin 26 (GJB2) genes that manifest during infancy and boceme more evident during adulthood. We herein report a case of VS in a 23-year-old female exhibiting sensorineural hearing loss, palmar keratoderma and homozygous deletion mutation delE120 (c.358-360delGAG) in the GJB2 gene. VS, is a rare genetic disorder, should be considered in patients with palmoplantar keratoderma and hearing loss and should be investigated connexin 26 (GJB2) gene mutation.

The protective effect of the proteasome inhibitor bortezomib on the uterus of ovariectomized rats.

Bortezomib (BORT) is an anti-tumour agent that inhibits proteasome, which is responsible for the degradation of many intracellular proteins. Although some side-effects and chemotherapeutic effects of BORT are known, there has not been enough research regarding its effects on different tissues of proteasome inhibition in the senile period (post-menopausal). The aim of this study was to investigate the safety of using BORT during the post-menopausal period. The post-menopausal effects of BORT were investigated on ovariectomized (OVX) Spraque-Dawley rats. The female rats were separated into three groups: control, ovariectomized (OVX), and OVX + BORT. OVX and OVX + BORT groups consisted of six rats in each. BORT was administered intraperitoneally in a dosage of 0.2 mg/kg two days a week for four weeks after OVX. The uteri of the rats were investigated using morphometrical, histopathological, and immunohistopathological methods. A striking atrophy in the endometrium and myometrium was observed due to an estrogen deficiency in the OVX group. The partial protective effect of BORT administration was observed morphometrically and histopathologically. In immunohistochemical research, cytoplasmic NF-KB activity was observed in the presence of proteasome inhibition in the endometrium. In light of these findings, the limited protective effects of post-menopausal BORT administration are worth mentioning.

Nigella sativa as a potential therapy for the treatment of lung injury caused by cecal ligation and puncture-induced sepsis model in rats.

We investigated the potential protective effects of Nigella sativa (NS) on mortality, serum levels of proinflammatory cytokines, oxidative stress and histopathological changes in lung tissues, in cecal ligation and puncture (CLP)-induced sepsis model in rats. Sepsis induction by CLP, determination of serum cytokine levels by ELISA, spectrophotometric determination of oxidative stress parameters, and histological examination of lung tissues. The rat groups were: 1) CLP group, 2) sham group, 3) NS500-sham group, 4) NS125, 5) NS250, 6) NS500 groups. NS treatment significantly decreased proinflammatory cytokine levels in serum; LPO level, MPO activity, and pathological changes in lung tissues, in CLP-induced sepsis, while significantly increasing GSH levels and SOD activity in the lung tissue. NS treatment after CLP potentially reduced mortality and may exert effects through the reduction in tissue oxidative stress and serum cytokines. The histopathological changes were minimized in lung tissue by NS, under sepsis conditions. We can suggest that NS reverses the systemic inflammatory reaction to polymicrobial sepsis and thereby reduces multiple organ failure. It may be suggested that role of the NS ethanolic extract in preventing formation of CLP induced sepsis, is due to the anti-inflammatory and antioxidant effects of the different compounds of the black seeds.

The effect of royal jelly on CD3(+), CD5(+), CD45(+) T-cell and CD68(+) cell distribution in the colon of rats with acetic acid-induced colitis.

BACKGROUND: Traditional medicines and health supplements have historically been used to treat many illnesses but most of them have not been evaluated objectively to prove their efficacy. We have been investigating the effects of royal jelly (RJ) supplements on acetic acid-induced colitis on the distribution of CD3(+), CD5(+), CD45(+) T-cell and CD68(+) cells in rats. METHODS: The rats were divided into four equal groups: control group, royal jelly-treated (RJ - 150mgkg(-1) body weight), acetic acid-treated (colitis) and acetic acid-treated (colitis)+royal jelly (CRJ - 150mgkg(-1) body weight). Colitis was induced by intracolonic instillation of 4% acetic acid; the control group received physiological saline (10mLkg(-1)). Colon samples were obtained under deep anaesthesia from animals in four groups. Tissues were fixed in 10% formalin neutral buffer solution for 24h and embedded in paraffin. RESULTS: The proliferative response of CD3(+) and CD45(+) T cells stimulated with colitis was affected by colitis treated with RJ. No differences were found in CD5(+) T cells and CD68(+) macrophages in the colitis treated with RJ. CONCLUSIONS: This study has shown that RJ has anti-inflammatory and cell regeneration effect in the colon of rats with acetic acid induced colitis.

Correction of Areolar Protuberance During Augmentation Mammoplasty in Transfemale Patients.

Augmentation mammoplasty refers to "top surgery" for transfemale patients. Before this surgery, due to the hormonal treatment being taken, it may be encountered that there would be a glandular tissue of breast that seems to be similar to the simple tuberous breast disease, which is one of the diseases in female breast development. The presence of areolar protuberance in transfemale would of course undermine the cosmetic gain after augmentation mammoplasty operation. This situation, which can be difficult to diagnose before surgery especially in transfemale patients, will manifest itself clearly after the end of augmentation mammoplasty. As a precaution, resection of a part of glandular tissue equal to the protruding height of the areola from the posterior wall of the gland is an effective method both in terms of its simple applicability and not to use of an extra skin incision while performing augmentation mammoplasty.

Exploring co-dispensed drug use in patients on sevelamer or polystyrene sulfonate to identify potential novel binding interactions: a cross sectional in silico study : Potential novel binding interactions with resins.

Background Sevelamer and polystyrene sulfonate are used for treating hyperphosphatemia and hyperkalaemia in chronic kidney disease patients. Because of their binding properties, these resins potentially bind other drugs in the gastrointestinal tract, thereby decreasing their bioavailability and clinical effectiveness. Aim The aim of this study was to explore co-dispensed drug use in patients on sevelamer or polystyrene sulfonate to identify potential novel binding interactions. Method In this in silico study, the 100 drugs most frequently co-dispensed with sevelamer/polystyrene sulfonate in the period 2000-2018 were extracted from the University Groningen IADB.nl database. Drugs dispensed to < 5% of patients, drugs not orally administered, drugs administered once daily before bedtime and drugs for which information on binding interactions with sevelamer or polystyrene was already available were excluded. The likelihood of an interaction (yes or no) of the included drugs was assessed based on pKa- and Log P values. For sevelamer, drugs with a pKa (acid) between 1.5 and 7.4 and or a Log P value > 2.0 were identified as potential interacting drug. For polystyrene sulfonate, drugs with a pKa (base) > 1.5 were identified as potential interacting drug. Results Of the top 100 drugs most frequently co-dispensed with sevelamer/polystyrene sulfonate, 22 and 27 potentially clinically relevant new interacting drugs were identified for sevelamer and polystyrene sulfonate respectively. Conclusion Several potentially relevant novel binding interactions for sevelamer and polystyrene sulfonate were identified based on dispensing data and assessment of chemical properties for which further interaction research is warranted.

Outcome of Very Low and Low Birth Weight Infants with Esophageal Atresia: Results of the Turkish Esophageal Atresia Registry.

INTRODUCTION: The data of the Turkish Esophageal Atresia Registry (TEAR) was evaluated to define the outcome of very low birth weight (VLBW) and low BW (LWB) infants with esophageal atresia (EA). MATERIALS AND METHODS: The data registered by 24 centers between 2014 and 2018 were evaluated for demographic features, prenatal findings, associated anomalies, surgical treatment, and outcome. Patients were enrolled in three groups according to their BWs (VLBW <1,500 g), LWB = 1,500-2,500 g), and normal BW (NBW; >2,500 g). RESULTS: Among the 389 cases, there were 37 patients (9.5%) in the VLBW group, 165 patients (42.4%) in the LBW group, and 187 patients (48.1%) in the NBW group. Prenatal diagnosis rates were similar among the three groups (29.7, 34.5, and 24.6%, respectively). The standard primary anastomosis was achieved at a significantly higher rate in NWB cases than in the other groups (p < 0.05). In patients with tracheoesophageal fistula (TEF), patients of the NBW group had significantly higher rates of full oral feedings, when compared with VLBW and LBW cases (p < 0.05). At the end of the first year, when we evaluate all patients, the number of cases with fistula recanalization and esophageal anastomotic strictures (AS) requiring esophageal dilatation was similar among the groups. The weight and height measurements at 6 months and 1 year of age of the survivors were similar in all the groups. The overall mortality rate was significantly higher in the VLBW and LBW groups, when compared with the NBW patients, even in patients with tension-free anastomosis (p < 0.05). The incidence of the associated anomalies was 90.6% in cases with mortality, which was significantly higher than in survivors (59.6%; p < 0.05). According to Spitz's classification, the survival rate was 87.1% in class I, 55.3% in class II, and 16.7% in class III. The most common causes of mortality were associated with cardiovascular diseases, pneumonia, and sepsis. CONCLUSION: The national data of TEAR demonstrates that the developmental and feeding parameters are better in NBW patients. Although VLBW patients have higher risk of developing fistula canalization than the LBW and NBW groups, long-term complications, such as anastomotic strictures, weight, and height values, after 1 year are similar in both groups. According to our results, associated anomalies and LBWs are still significant risk factors for mortality in cases with EA.

Neurally-mediated sincope.

Syncope is a syndrome characterized by a relatively sudden, temporary and self-terminating loss of consciousness; the causes may vary, but they have in common a temporary inadequacy of cerebral nutrient flow, usually due to a fall in systemic arterial pressure. However, while syncope is a common problem, it is only one explanation for episodic transient loss of consciousness (TLOC). Consequently, diagnostic evaluation should start with a broad consideration of real or seemingly real TLOC. Among those patients in whom TLOC is deemed to be due to ''true syncope'', the focus may then reasonably turn to assessing the various possible causes; in this regard, the neurally-mediated syncope syndromes are among the most frequently encountered. There are three common variations: vasovagal syncope (often termed the ''common'' faint), carotid sinus syndrome, and the so-called ''situational faints''. Defining whether the cause is due to a neurally-mediated reflex relies heavily on careful history taking and selected testing (e.g., tilt-test, carotid massage). These steps are important. Despite the fact that neurally-mediated faints are usually relatively benign from a mortality perspective, they are nevertheless only infrequently an isolated event; neurally-mediated syncope tends to recur, and physical injury resulting from falls or accidents, diminished quality-of-life, and possible restriction from employment or avocation are real concerns. Consequently, defining the specific form and developing an effective treatment strategy are crucial. In every case the goal should be to determine the cause of syncope with sufficient confidence to provide patients and family members with a reliable assessment of prognosis, recurrence risk, and treatment options.

Routine interval appendectomy is unnecessary after conservative treatment of appendiceal mass.

OBJECTIVE: The traditional management of appendiceal mass is initial conservative treatment followed by interval appendicectomy. Recently interval appendicectomy has been questioned by a growing amount of evidence. The purpose of this study was to clarify the role of interval appendicectomy after successful initial conservative treatment. METHOD: The study included 98 patients with a mass in the right iliac fossa. Four (4%) patients were excluded wing to another diagnosis of appendiceal mass including caecal cancer (two), diverticulitis (one), and Crohn's disease (one). The remaining 94 patients were treated conservatively. Routine interval appendicectomy was not performed after successful conservative treatment. RESULTS: Ultrasound (US)-guided drainage was performed in seven (7.4%) patients. Two were drained surgically because of a persistent abscess despite a previous US-guided drainage. In five (5.3%) patients, a delayed operation was necessary because of complications. One patient developed small bowel obstruction, and in three patients, conservative treatment was unsuccessful with the abscess remaining unresolved. Within 3 months, seven out of the 89 patients were readmitted to hospital with a recurrent mass in two patients and acute appendicitis without a mass in five patients. Six (6.7%) patients were readmitted with recurrent appendicitis after 3 months. The recurrence rate after successful conservative treatment was 14.6%. The majority (nine patients; 10.1%) of the recurrences occurred within the first 6 months, and after 1 year the recurrence rate was very low (two patients; 2.2%). CONCLUSION: Routine interval appendicectomy after initial successful conservative treatment is not justified and should be abandoned. At present, there is no consensus for the management of appendiceal mass. There is, therefore, a need to develop a protocol for the management of this common problem.

Comparison of intraocular pressure lowering effect of once daily morning vs evening dosing of latanoprost/timolol maleate combination.

PURPOSE: To compare intraocular pressure (IOP) reduction profiles of latanoprost-timolol maleate fixed combination (LTFC) administered in the morning or evening in primary open angle glaucoma (POAG). METHODS: A prospective, randomized study including 60 eyes of 30 patients with POAG was carried out. Patients were randomized to treatment with LTFC at 8 PM (Group 1) or at 8 AM (Group 2). After therapy of 4 weeks, IOP was measured at 2 AM, 6 AM,10 AM, 2 PM, 6 PM, and 10 PM and compared with baseline values and latanoprost therapy alone. RESULTS: Mean diurnal baseline IOPs and IOPs after treatment with latanoprost and LTFC were 23.6+/-2.6, 16.7+/-2.3, and 15.5+/-2.2 mmHg in Group 1 and 23.1+/-2.6, 16.9+/-2.4, and 15.7+/-2.4 mmHg in Group 2. LTFC lowered IOP more than latanoprost at all time points in both groups (p<0.001) (except 6 AM in Group 2). The mean IOP range after LTFC therapy was lower than the baseline in Group 1 whereas it was not different in Group 2. IOP at 10 AM was significantly higher than the other time points at baseline measurements in both groups (p<0.01) but after treatment there was no difference (p>0.05). According to IOP reduction from baseline, there was a statistically significant difference between groups in favor of Group 1 at 6 AM, 10 AM, and mean diurnal measurement (p<0.01). CONCLUSIONS: Both morning and evening dosing of LTFC were effective in lowering diurnal IOP in patients with POAG. However, evening dosing of LTFC seemed to be more effective in controlling IOP especially in the morning and avoiding the fluctuations with lower range of IOP.

Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin.

PURPOSE: To evaluate the intraoperative findings, complication rates, effect of intracameral adrenaline, and incidence of intraoperative floppy iris syndrome (IFIS) in patients using tamsulosin. METHODS: In this prospective nonrandomized observational study, 858 eyes of 774 patients who had phacoemulsification between August 2005 and November 2006 were evaluated. Duration and preoperatively discontinuing time of tamsulosin intake were questioned. Preoperative pupil size, intraoperative iris behavior, progressive miosis, adrenalin usage, and complications were recorded. RESULTS: The incidence of IFIS was 1.6% and IFIS was seen in 14 of the 18 eyes of patients using tamsulosin (77.8%). One eye had floppy iris only, 2 eyes had floppy iris and intraoperative miosis, 3 eyes had floppy iris and iris prolapse, and 8 eyes had all three signs of IFIS. IFIS was seen in 7 of the 10 eyes where intracameral adrenaline was used, and in 7 of the 8 eyes without adrenaline (p=0.588). Intraoperative miosis was seen only in 3 of the 10 eyes with adrenaline and in 7 of the 8 eyes without adrenaline (p=0.025). Posterior capsule rupture occurred in 1 of the eyes with IFIS and in 5 eyes focal iris stromal atrophy caused by prolapse was seen. CONCLUSIONS: IFIS occurred in 1.6% of cases having phacoemulsification. Intracameral adrenaline usage did not change the IFIS occurrence rate, but it seemed to be effective in preventing intraoperative miosis. There are still many questions about IFIS, and there is need for future studies strengthening the understanding of IFIS.

The approach taken by the physicians working at educational hospitals in Izmir towards patient rights.

OBJECTIVE: Considered as a reflection of human rights in our modern day, patient rights have been gaining increasing importance. This particular subject has been discussed from various perspectives in different countries and legal sanctions imposed. "Patient Rights Directives" in Turkey came into effect in 1988. The present study was carried out in order to determine how well the physicians working in Izmir, the third largest city of Turkey, are aware and informed of these directives. METHODS: Our study is an observational-cross sectional descriptive one. The research was conducted among the physicians working in nine training hospitals in Izmir province using a random sampling method. 1,500 questionnaires with 19 multiple-choice questions were distributed in the study. 567 of the forms were returned. Statistical assessment of the data obtained was carried out using the x(2) test on SPSS 10.0 Windows Program. RESULTS: Of the physicians participating in the study, 43% were female and 57% male. The average age was 32 +/- 7.76 years. 40% of the participating physicians were not aware of the legal arrangements (directive). 63% of the participants stated that they had not read any kind of legislation related to patients' rights. Only 34% of the participants knew that the legal sanctions were put into effect in the form of "directive." CONCLUSION: Legal arrangements related to patient rights in the world are being put into effect within the framework of human rights. Turkey is one of the first countries to have completed the legal procedures in this field. PRACTICE IMPLICATIONS: We believe it is necessary that this particular issue be included both in the training programs of the medical faculties and supported by all parts of the society including physicians if these legal procedures are to work effectively.

Malpractice and system of expertise in anaesthetic procedures in Turkey.

Deaths which occur during the administration of anaesthetics require medicolegal investigations. The objective of this study is to form a database for future comparisons related to anaesthetic-associated malpractice claims and also to investigate the system of expertise, pertaining to such procedures. The decisions of the Supreme Health Council, whose expert opinion is requested by legal authorities (judges, prosecutors) for health workers brought to trial in a criminal court, were examined retrospectively over the period 1995-1999. In 21 (2.3%) of the 888 decision reports prepared by the council the team members (the anaesthesiologist , the anaesthetic assistant, the anaesthetic technician, the nurse) were directly interrogated. Data concerning these 21 council decisions were evaluated within the scope of this study. It was found that 57% of the 21 decisions were related to medical procedures carried out in state hospitals. Of the 21 cases, 62% were males, 38% females. General anaesthesia was applied to 19 of the cases while one received regional (local) anaesthesia and one axillary blockade. Twenty died of complications associated with anaesthesia. Autopsy was performed on 11 (55%) of the dead. Health workers were found to have different degrees of liability in the 16 (76%) of the 21 decision reports. In their medical practices, anaesthesiologists , like other specialists, are subject to legal procedures in the country where they perform their duties, to national and international principles of ethics, and to diagnostic and curative standards/procedures relevant to the scientific level of the country concerned. In anaesthetic malpractice claims, certain standards need to be followed in inquiries and approaches so as to determine the real reasons behind the disabilities and/or deaths which occur. In order that sound evaluations could be made in such cases, the experts as well as the system of expertise should be efficient and authorized.

Colour Doppler imaging of the orbital vasculature in Graves' disease with computed tomographic correlation.

AIMS: To evaluate alterations in orbital blood flow parameters and their correlations with extraocular muscle enlargement, proptosis, and intraocular pressure in patients with Graves' disease. METHODS: In this multicentre study blood flow parameters in the ophthalmic artery, superior ophthalmic vein, central retinal artery and vein were determined by colour Doppler imaging in 111 patients with Graves' disease in two groups (A and B) and 46 normal control subjects. Group A consisted of 42 patients with Graves' disease without ophthalmopathy; group B of 69 patients with Graves' disease with ophthalmopathy as detected by orbital computed tomographic scanning. RESULTS: Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein in patients in group B were statistically significantly higher than those in group A and the normal controls, whereas maximal and minimal velocities in the superior ophthalmic vein in patients in group B were statistically significantly lower than those in group A and the control subjects. Peak systolic and end diastolic velocities in the ophthalmic artery, peak systolic velocity in the central retinal artery, and maximal and minimal velocities in the central retinal vein also correlated with the sum of all extraocular muscle diameters in group B (r > or =0.31, p< or =0.021). Blood flow parameters had no consistent correlation with proptosis or intraocular pressure (p>0.05). No statistically significant difference was found in resistivity indices between the groups (p>0.05). Reversed blood flow was noted in nine (13%) superior ophthalmic veins in group B. CONCLUSION: Orbital blood flow velocities are altered in patients with Graves' ophthalmopathy and may be detected by colour Doppler imaging. Some of these changes also correlate with the enlargement of extraocular muscles. The increased blood flow velocities in arteries may be secondary to orbital inflammation.

Quantitative CT of the orbit in Graves' disease.

In order to determine the value of quantitative CT of the orbit in patients with Graves' disease, we clinically examined 174 orbits of 87 patients with Graves' disease and evaluated them by CT in respect to the density and size of the extraocular muscles, the globe position and the width of the optic nerve-sheath complex. We also determined the normal ranges for density of extraocular muscles in 200 normal orbits of 100 patients for comparison. Normal ranges for the density of extraocular muscles were (mean +/- 2 SD) medial rectus, 28-63 HU; lateral rectus, 24-78 HU; inferior rectus, 20-64 HU; superior muscle group, 28-62 HU. 51 of 77 (66%) patients with Graves' disease had extraocular muscle density changes. Some extraocular muscles showed fatty infiltration on CT. 50 of 87 (57%) patients had at least one enlarged extraocular muscle, 47 (54%) patients had exophthalmos and 59 (68%) patients had either exophthalmos and/or extraocular muscle enlargement. A diagnosis of Graves' ophthalmopathy was made in 69 of 87 (79%) patients using CT and in 50 (57%) patients by clinical examination. We conclude that quantitative CT imaging of the orbit with evaluation of the size and density values of extraocular muscles and the globe position may be very helpful in detecting ophthalmopathy in patients with Graves' disease.

Ptosis surgery using Mersilene mesh suspensory material.

Frontalis suspension procedure using a Mersilene mesh sling was performed on 23 ptotic eyelids of 22 patients (age range 3 to 35 years) with poor or absent levator function. The surgical technique used was a modified Fox's method. The mean palpebral fissure height was 3.1 mm preoperatively and increased to 8.0 mm after the operation. No serious complication was seen postoperatively and during an average follow-up of 25 months. In one case with a cosmetically inadequate result, the upper third of the initially implanted Mersilene mesh was removed during reoperation and histological examination of the specimen revealed fibrovascular tissue invasion through the mesh fibres. Mersilene mesh appears to be an effective and safe alternative sling material for brow suspension surgery, giving good permanent results for cases in which autogenous fascia lata was inappropriate.