Dynamic thiol-disulphide homeostasis as a biomarker for predicting the development of contrast medium-associated acute kidney injury in the endovascular treatment of peripheral arterial disease: should intravenous N-acetylcysteine be given before the procedure?

AIM: To determine the predictive ability of serum thiol-disulphide levels for contrast medium-associated acute kidney injury (CA-AKI) after endovascular treatment (EVT) of peripheral arterial disease (PAD) and evaluate the efficacy of intravenous N-acetylcysteine (NAC) in preventing CA-AKI. MATERIAL AND METHODS: This double-blind, randomised controlled study included 85 consecutive adult patients who underwent EVT for PAD. Patients were divided into NAC negative (NAC-) and positive (NAC+) groups. While the NAC- group received only 500 ml saline, the NAC + group received 500 ml saline plus intravenous 600 mg NAC before the procedure. Intra- and intergroup patient characteristics, procedural details, preoperative thiol-disulphide levels, and ischaemia-modified albumin (IMA) levels were recorded. RESULTS: There was a significant difference between NAC- and NAC + groups regarding native thiol, total thiol, disulphide/native thiol ratio (D/NT), and disulphide/total thiol ratio (D/TT). There was also a significant difference between the NAC- (33.3%) and NAC+ (13%) groups in CA-AKI development. Logistic regression analysis showed that the D/TT (OR 2.463) and D/NT (OR 2.121) were the most influential parameters for CA-AKI development. In the receiver operating characteristic (ROC) curve analysis, the sensitivity of native thiol to detect the development of CA-AKI was 89.1%. The negative predictive values of native thiol and total thiol were 95.6% and 94.1%, respectively. CONCLUSION: The serum thiol-disulphide level can be used as a biomarker to detect CA-AKI development and reveal patients with a low risk for CA-AKI development before EVT of PAD. Furthermore, thiol-disulphide levels allow for the indirect quantitative monitoring of NAC. Preprocedural intravenous NAC administration significantly inhibits CA-AKI development.

The impact of the COVID-19 pandemic on the orthopaedics outpatient clinic.

OBJECTIVE: The COVID-19 pandemic has significantly impacted orthopaedic practice since it started. In our study, we aimed to examine these effects on outpatient services. PATIENTS AND METHODS: The patients who applied to the orthopedic outpatient clinic (n=1,518) in six months period under the effect of the COVID-19 pandemic (September 2020-March 2021) and patients (n=1,207) who applied during the same period before the pandemic (September 2019-March 2020) were analyzed according to the demographic characteristics (age, gender), reasons for admission, duration of complaints, treatments applied, surgical acceptance rate, and compliance with treatment. RESULTS: The mean age in the pre-pandemic outpatient clinic admissions was 39.1 years (1-91 years), the gender ratio was 635/572 (Female/Male), the mean age of the patients was 38.1 years (1-95), and the sex ratio was 793/725 (F/M) during the pandemic. Admissions of patients with acute complaints decreased after the pandemic, and applications for subacute or chronic complaints increased. Applications for sports medicine, pediatrics, and hand surgery increased, applications for trauma, foot and ankle surgery decreased, and applications for oncology and spine did not change. Conservative treatment recommendations decreased, the surgical treatment recommendation did not change, and the rate of patients who were given only follow-up decisions increased. There was no significant difference in the treatment rejection and surgical acceptance rate. CONCLUSIONS: We observed that the number of traumas decreased, and the hospital admission duration extended. The increase in the consultation rate and follow-up preference indicates that the treatment is more conservative in this period. In this process, patients should be adequately informed about the precautions taken, and their treatment should not be interrupted.

Clinical and demographic features of hidradenitis suppurativa: a multicentre study of 1221 patients with an analysis of risk factors associated with disease severity.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, relapsing and debilitating inflammatory disease associated with profound morbidity. AIM: In this multicentre study, we investigated the demographic and clinical features of HS, and determined risk factors of disease severity. METHODS: In total, 1221 patients diagnosed with HS from 29 centres were enrolled, and the medical records of each patient were reviewed. RESULTS: The mean age of disease onset was 26.2 ± 10.4 years, and almost 70% (n = 849) of patients were current or former smokers. Mean disease duration was 8.9 ± 8.4 years with a delay in diagnosis of 5.8 ± 3.91 years. Just over a fifth (21%; n = 256) of patients had a family history of HS. The axillary, genital and neck regions were more frequently affected in men than in women, and the inframammary region was more frequently affected in women than in men (P < 0.05 for all). Acne (40.8%), pilonidal sinus (23.6%) and diabetes mellitus (12.6%) were the most prevalent associated diseases. Of the various therapies used, antibiotics (76.4%) were most common followed by retinoids (41.7%), surgical interventions (32.0%) and biologic agents (15.4%). Logistic regression analysis revealed that the most important determinants of disease severity were male sex (OR = 2.21) and involvement of the genitals (OR = 3.39) and inguinal region (OR = 2.25). More severe disease was associated with comorbidity, longer disease duration, longer diagnosis delay and a higher number of smoking pack-years. CONCLUSIONS: Our nationwide cohort study found demographic and clinical variation in HS, which may help broaden the understanding of HS and factors associated with disease severity.

The effect of alpha­lipoic acid on oxidative parameters and liver injury in rats with obstructive jaundice.

INTRODUCTION: The aim of this study is to investigate the effects of obstructive jaundice on the liver and effectivity of alpha­lipoic acid on liver damage and oxidative stress. MATERIALS AND METHODS: Thirty­six male Sprague­Dawley rats were divided into 3 groups per 12 animals, namely into Group I (control group): the bile duct was only mobilized by laparotomy, Group II (bile duct ligation group - BDL): the common bile duct was closed with clips and OJ was caused after laparotomy, and Group III (bile duct ligation and alpha­lipoic acid group - BDL+LA): after closing the common bile duct, LA was administered in an intramuscular dose of 50 mg/kg for 10 days. On the 10th day, malondialdehyde, glutathione and superoxide dismutase levels were measured in liver and histopathological evaluation was performed. RESULTS: AST (U/L)/ALT(U/L) in groups I, II and III were 155.33/51.83, 445.28/165.89, 380.78/173.33, respectively (p < 0.005). Superoxide dismutase and glutathione levels were lower in patient groups than in the control group (0.31 µl/g vs 0.36 µl/g; p < 0.05). After the lipoic acid treatment, none of the biochemical markers of liver improved. Only the increase in superoxide dismutase (0.31 µl/g and 0.34 µl/g in groups II and III, respectively) and glutathione levels (0.16 µl/g and 0.22 µl/g in groups II and III, respectively) was statistically significant (p < 0.05). CONCLUSIONS: Histopathological damage was statistically significantly decreased and antioxidant levels were statistically significantly increased after LA treatment (Tab. 1, Fig. 6, Ref. 23).

Percutaneous endobiliary radiofrequency ablation for refractory benign hepaticojejunostomy and biliary strictures.

PURPOSE: The objective of this study was to determine the safety and efficacy of percutaneous endobiliary radiofrequency ablation (ERFA) and balloon dilation for the treatment of hepaticojejunostomy (HJ) strictures resistant to surgery and/or other interventions. MATERIALS AND METHODS: Eighteen patients who underwent percutaneous ERFA for HJ stricture were included. There were 10 men and 8 women with a mean age of 48.3±10.8 (SD) years (range: 33-69 years). The 18 patients had a total of 29 benign HJ strictures secondary to cholecystectomy (14 patients; 78.0%), Whipple procedure (3 patients; 16.6%) or blunt abdominal trauma (1 patient; 5.4%). The different end-points were technical success, clinical success, recurrence, procedure-related mortality, and morbidity. RESULTS: Technical and clinical success rates were 100% and 83.3%, respectively. No mortality and major procedure-related complications were observed. One patient experienced minor complication (self-limited pleural effusion). Two patients did not show favorable response to ERFA whereas 10 patients had no stricture recurrence during a mean follow-up period of 7.3 months±1.0 (SD) (range: 4-10 months). CONCLUSION: ERFA is a safe and effective treatment for benign HJ and biliary strictures. However, more studies involving more patients with a long-term follow-up period should be made to fully determine the long-term results of ERFA.

Hematopoietic Stem Cell Transplant for Primary Immunodeficiency Diseases: A Single-Center Experience.

OBJECTIVES: The only curative treatment for many patients with primary immunodeficiency disease is hematopoietic stem cell transplant. In this study, we report the transplant outcomes of patients with primary immunodeficiency diseases. MATERIALS AND METHODS: Herein, we present the transplant outcomes of 20 patients with primary immunodeficiency disease seen at our center in Kayseri, Turkey, from 2010 to 2015. RESULTS: The disease distribution of the 20 patients were as follows: 6 patients with severe combined immunodeficiency, 4 patients with hemophagocytic lymphohistiocytosis, 2 patients with chronic granulomatous disease, 2 patients with type 2 Griscelli syndrome, 2 patients with B-cell deficiency plus bone marrow failure, 1 patient with severe congenital neutropenia, 1 patient with X-linked lymphoproliferative disease, 1 patient with T-cell deficiency plus relapsed non-Hodgkin lymphoma, and 1 patient with type 1 leukocyte adhesion deficiency. Of the 20 patients, 11 received related HLA-matched, 6 received haploidentical, 2 received unrelated HLA-matched, and 1 received HLA-mismatched transplant. The median age at transplant was 21 months, and median follow-up was 5 months. Overall survival rate was 65%. Mean engraftment times for neutrophils and platelets were 14.25 ± 3.08 and 24.7 ± 11.4 days. Graft-versus-host disease was observed in 30% of patients. CONCLUSIONS: Patients with primary immunodeficiency disease treated at our center had acceptable transplant outcomes. This study supports the use of hematopoietic stem cell transplant in patients with primary immunodeficiency disease.

The effect of proximal anastomosis on the expansion rate of a dilated ascending aorta in coronary artery bypass surgery: a prospective study.

BACKGROUND: This study was designed to determine the short- and long-term effects of proximal aortic anastomosis, performed during isolated coronary artery bypass grafting (CABG) in patients with dilatation of the ascending aorta who did not require surgical intervention. METHODS: The study was performed on 192 (38 female and 160 male patients; mean age, 62.1 ± 9.2 years; range, 42-80 years) patients with dilatation of the ascending aorta who underwent CABG surgery between 1 June 2006 and 31 May 2014. In group 1 (n = 114), the saphenous vein and left internal mammarian artery grafts were used, and proximal anastomosis was performed on the ascending aorta. In group 2 (n = 78), left and right internal mammarian artery grafts were used, and proximal aortic anastomosis was not performed. Pre-operatively and in the first and third years postoperatively, the ascending aortic diameter was measured and recorded using transthoracic echocardiography at four different regions (annulus, sinus of Valsalva, sinotubular junction and tubular aorta). RESULTS: A statistically significant difference was found between the groups for the number of grafts used and the duration of aortic cross-clamping and cardiopulmonary bypass. No significant intergroup difference was seen for the mean diameter of the ascending aorta (p > 0.05). Annual changes in the aortic diameter were found to be extremely significantly different in both groups (p = 0.0001). Mean values of the aortic diameter at the level of the sinotubular junction and tubular ascending aorta, mean aortic diameters (p = 0.002 and p = 0.0001, respectively), annual increase in diameter (p = 0.0001 and p = 0.0001, respectively), and mean annual difference in diameter (p = 0.0001 and p = 0.0001, respectively) at one and three years postoperatively were statistically significantly different between the groups. CONCLUSION: In patients with ascending aortic dilatation who did not require surgical intervention and who had proximal anastomosis of the ascending aorta and underwent only CABG, we detected statistically significant increases in the diameter of the sinotubular junction and tubular aorta up to three years postoperatively.

Predictive Value of Unenhanced Computerized Tomography for Detecting Hepatosteatosis in Living Liver Donors.

OBJECTIVE: Macrovesicular hepatosteatosis is related to post-transplantation complications, so preoperative hepatosteatosis determination plays a critical role in donor selection. The aim of this study was to evaluate the efficacy of unenhanced computerized tomography (CT) in determining hepatosteatosis in liver donor candidates. METHODS: Information about donor candidates was retrospectively reviewed. In this screening, 27 donor candidates who underwent liver biopsy because of suspected hepatosteatosis in routine abdominal CT examination before transplantation, were reviewed. Liver biopsies and CT images were reevaluated by an experienced pathologist and radiologist. Macrovesicular hepatosteatosis was graded according to percentage and divided into 3 groups. Three radiologic liver attenuation indices were used: 1) hepatic attenuation value (CT(L)); 2) the difference between hepatic attenuation and spleen attenuation (CT(L-S)); and 3) the ratio of hepatic attenuation to splenic attenuation (CT(L/S)). RESULTS: CT(L), CT(L-S), and CT(L/S) values of donors with hepatosteatosis were significantly higher than the donors without hepatosteatosis. In receiver operating characteristic analysis, the optimal cutoff value of these indices for determining hepatosteatosis were; 42.5, -5, and 0.98, respectively. At these cutoff values, the sensitivity and specificity of these indices were calculated to be 80% and 75%, 93.3% and 83.3%, and 93.3% and 83.3%, respectively. There were no statistical differences between their diagnostic performances. When these 3 indices were used for detect significant hepatosteatosis (>20%) it was observed that hepatosteatosis of only one donor could not be determined whereas it was seen that specificity was decreased markedly. CONCLUSIONS: Despite the high diagnostic yield of unenhanced CT, it is not suitable to use alone for assessment of hepatosteatosis in clinical practice.

Look-back study on recipients of Parvovirus B19 (B19V) DNA-positive blood components.

BACKGROUND AND OBJECTIVES: To assess the relevance of Parvovirus B19 (B19V) DNA at low to intermediate concentrations in blood donors for the recipients of their blood components. MATERIAL AND METHODS: We studied recipients of B19V DNA-positive blood components [red blood cell concentrates (RBCs), pooled platelet concentrates and fresh frozen plasma]. This included archived pretransfusion samples as well as follow-up samples investigated by ELISA or NAT and genome sequence analysis. RESULTS: In 132 out of 424 recipients, we could detect no anti-B19V IgG before transfusion. In 67 out of 132 sero-negative recipients, a follow-up sample was available. Sixty-five of these received blood components from donors with <10(4) IU B19V DNA/ml plasma and had no evidence of transfusion-transmitted (TT)-B19V infection. Homology in genome sequences in donor and recipient provided evidence for a TT-B19V infection in two recipients. Both patients received RBC containing 3.4 × 10(6) and 1.8 × 10(4) IU B19V DNA/ml plasma, respectively. The anti-B19V IgG titres in the donors were 2 and 76 IU/ml plasma, respectively. The antibodies in the second donor were directed against capsid proteins and are thus considered as potential neutralizing antibodies. CONCLUSIONS: TT-B19V infections through blood components with low (<10(4) IU/ml plasma) B19V DNA concentrations did not occur in our study. One of the TT-B19V infections occurred from RBC with intermediate B19V DNA concentration despite the presence of potential neutralizing antibodies in the donor, but its clinical significance was low.

Comparison of Patients in Whom Double-J Stent Had Been Placed or Not Placed After Renal Transplantation in a Single Center: A Follow-up Study.

BACKGROUND: Double-J (DJ) stents play an important role in modern urology to prevent undesirable side effects after surgery. We aimed to investigate the relationship of DJ stents with the demographic characteristics, surgical complications, urinary tract infection (UTI), and hematuria in the patients who underwent renal transplantation (Tx). METHODS: Data of 354 patients who underwent renal Tx between 2008 and 2011 at Ege University were evaluated retrospectively; 331 patients were included in this study. The term DJ (-) represents patients in whom a DJ stent was not placed. "Primary DJ term" represents patients in whom the DJ stent was placed during the first Tx. "Secondary DJ term" represents the patients who had DJ after Tx for any complication. RESULTS: Two hundred fifty-four (76.7%) patients were in the DJ (-) group, 52 (15.7%) were in the primary DJ group, and 25 (7.6%) were in the secondary DJ group. There were significant differences between the groups in terms of anastomosis type (P = .000), stay-in-hospital time (P = .000), surgical complication (P = .000), re-operation (P = .000), percutaneous nephrostomy (P = .000), UTI (P = .000), first-time UTI (P = .000), recurrent UTI (P = .000), positive hemoculture (P = .000), hematuria (P = .000), duration of dialysis before Tx (P = .000), live/deceased donor (P = .000), and delayed graft function (P = .009). CONCLUSIONS: Our choice is to use the DJ stent in selected high-risk patients and to keep the indications for DJ stent wider in deceased donor transplants by considering possible surgical complications. The use of the stent only in selected cases will decrease surgical complications due to stent placement.

A case of successful renal transplantation for hydatid disease after surgical treatment of disseminated cysts.

Hydatid disease is a systemic disorder affecting especially the liver and lungs. Although it is not endemic in Europe, it can be seen sporadically, particularly because of travel and immigration. Severe, multiple organ involvement is quite rare. A 39-year-old Kurdish male patient presented with the previous diagnosis of hydatid disease and disseminated cysts in the liver, lung, and left kidney, leading to renal failure and the need for hemodialysis. Following multiple operations, complete eradication of infectious cysts was achieved, and kidney transplantation was performed. After 4 years of follow-up, the patient is in good condition, especially with normal renal function and no sign of recurrent hydatid disease.

Unusual case of frontal mucocele presenting with forehead ulcer.

Paranasal mucoceles are benign slow-growing paranasal sinus lesions, which usually develop following the obstruction of the sinus ostiu. They most frequently occur in the frontal sinus. Frontal mucoceles are expansive lesions usually causing visual clinical signs and symptoms such as diminution of vision, visual field defects, diplopia, orbital swelling, retroorbital pain, displacement of eye globe, ptosis, and proptosis. When the frontal mucocele extends intracranially, it can manifest with meningitis, meningoencephalitis, intracranial abscess, seizures, or cerebrospinal fluid fistula. Very rarely it can cause forehead swelling. We report an 80-year-old woman presenting with a forehead skin ulcer and painless subcutaneous forehead induration. Histopathologic examination revealed mucin deposition and inflammation. Computerized tomography (CT) and magnetic resonance imaging (MRI) scans showed a mass originating from the frontal sinus with frontal bony defect and frontocutaneous fistula. Surgical excision of the mass confirmed the mucocele diagnosis. In this article, we present a case of frontocutaneous fistula and skin ulcer, which is an unexpected complication of frontal mucocele. We propose that in the case of a localized non-healing ulcerated forehead skin lesions, mucocele should be considered in the differential diagnosis.

Atypical severe combined immunodeficiency caused by a novel homozygous mutation in Rag1 gene in a girl who presented with pyoderma gangrenosum: a case report and literature review.

Severe combined immunodeficiency (SCID) is a heterogeneous group of inherited defects involving the development of T- and/or B-lymphocytes. We report a female with atypical severe combined immunodeficiency caused by a novel homozygous mutation at cDNA position 2290 (c.2290C > T) in exon 2 of the RAG1 gene. The patient presented with bronchopneumonia, pyoderma gangrenosum (PG), pancytopenia and splenomegaly. She presented to us with pancytopenia and splenomegaly at the age of 11. Her condition was complicated by PG on left lower ankle at the age of 12. She experienced bronchopneumonia at the age of 15. She was diagnosed with RAG1 deficiency at the age of 16. Her immunological presentation included leucopenia and diminished number of B cells.

Unusual localization of an unusual tumor: calcifying pseudoneoplasm of the foramen magnum.

OBJECTIVE: We report a rare case of calcifying pseudoneoplasm in the foramen magnum. A large variety of tumors can be found in the foramen magnum; meningiomas, neurofibromas, chordomas, chondrosarcomas and metastases are among those that have been reported. Based on the histopathological structure of the tumor, radical excision or, in the case of tumors with good behavioral pattern, only decompressive debulking can be applied, in an effort to avoid unnecessary morbidities. Thus, it is important to know the nature of the tumor before planning the surgery. CASE REPORT: A 53-year-old man with a 1-year history of pain on the left side of his face was admitted to our service. Magnetic resonance imaging revealed a calcific mass at the left side of the spinal cord at the level of the foramen magnum. Median suboccipital craniectomy and total tumor resection were performed and there was no additional neurological deficit postoperatively. CONCLUSION: We report, to our knowledge, the second case of a calcifying pseudoneoplasm of the foramen magnum. We emphasize that these tumors are pathologically benign and do not require aggressive surgical treatment and suggest that asymptomatic cases can be followed radiologically.

The effectiveness of radioisotope synovectomy for chronic synovitis in Turkish paediatric haemophiliacs: Ankara experience.

Between January 2006 and December 2009, 37 radioisotope synovectomy (RS) in 18 severe haemophilic patients (factor 8<1%) have been performed at our centre. The distribution of joint injected was as follows: rhenium-186 [Re186], 19 joints (ankles, 8 and elbows, 11) and yttrium-90 [Y90] 18 joints (knees, 18). Their mean age was 12 years (range: 8-20 years). Mean follow-up period after procedure was 22.6 months. We preferred to use Y90 for all large joints and Re186 for small joints. Haemophilic patients with grade-II or III synovitis were selected for RS in our study. Radioisotope synovectomy was performed in eight ankles for seven patients, 11 elbows for seven patients and 18 knees for 13 patients. Mean bleeding counts before the procedure and after the procedure were as follows: Ankles, 3.43 vs. 0.62 (P=0.002); elbows, 3.12 vs. 0.55 (P=0.000); and 3.83 vs. 0.62 (P=0.011). No major complications requiring secondary treatments were observed. In summary, an early RS is the best way to halt the evolution of chronic haemophilia synovitis to devastating haemophilic arthropathy. Radioisotope synovectomy is very effective and safe in the treatment of chronic synovitis of children with haemophilia. Our data confirm the efficacy of RS for the treatment of chronic haemophilic synovitis, which has been previously published by many authors around the world. We highly recommend this procedure for developing countries to prevent joint disabilities. For a better and a healthier generation, RS has to be introduced in all the developing countries.

Evaluation and comparison of three different anti-hepatitis C virus antibody tests based on chemiluminescence and enzyme-linked immunosorbent assay methods used in the diagnosis of hepatitis C infections in Turkey.

The routine diagnosis of hepatitis C virus (HCV) infection is based on the detection of anti-HCV antibodies by two main methods (enzyme immunoassay [EIA] and chemiluminescence immunoassay [CIA]) but false-positives are a problem. We investigated three anti-HCV tests: two CIAs (Cobas e 601 and Architect i2000SR); and one EIA (Ortho HCV 3.0). Two other anti-HCV tests were also performed as supplementary and confirmatory tests, respectively: a recombinant strip immunoblot assay (RIBA HCV 3.0 SIA) and a reverse transcriptase polymerase chain reaction-based assay for HCV-RNA. After discriminating the false-positive results, the true anti-HCV seropositivity rate in 7156 serum samples was 0.91%. The seropositivity and false-positive rates for the Cobas e 601, Architect i2000SR and Ortho HCV 3.0 anti-HCV tests were 1.9% and 0.99%, 1.2% and 0.29%, and 0.87% and 0.01%, respectively. The mean level of HCV-RNA was 3399 x 10(3) IU/ml. Critical levels for false-positivity for HCV-RNA were a cut-off index of 200 for Cobas e 601, a signal/cut-off (S/CO) of 5 for Architect i2000SR and an S/CO of 1.2 for Ortho HCV 3.0. Positive and negative results for the RIBA HCV 3.0 SIA assay all accorded with the HCV-RNA assay, except for 23 (17%) 'indeterminate' results, all of which were negative with the HCV-RNA assay. In conclusion, to eliminate doubts related to false-positive findings in the initial HCV screening tests, additional confirmatory HCV-RNA assay should be performed.

Medical malpractice claims involving children.

AIM: The aim of this study was to reveal and discuss the profile of medical malpractice claims involving children aged 0-18 years and reported to the Supreme Health Council (SHC), an organization providing expert opinion for malpractice claims in Turkey. METHODS: We retrospectively reviewed 167 children cases among 960 malpractice claims which expert opinion was provided by SHC between 1996 and 2000. RESULTS: Out of 167 children, 64.1% were male. Most of the children were aged 6-12 years. 63.5% of the claims were associated with crime lawsuits. 59.3 and 31.7% of the children applied to hospitals due to diseases and accidents, respectively. More than half of the malpractices occurred in state hospitals (63.5%) and resulted from non-surgical interventions (58.7%). One-thirds of the children suffered from infections. 57.5% of the children (n=96) died and 59.3% of them (n=57) were autopsied. Health staff was found at fault in 46.1% of the claims. Causes of deaths reported before and after autopsies were conflicting in 13 of 19 autopsied children (68%). CONCLUSION: We think that the results of this study will contribute to the data about the profile of medical malpractice claims involving children will increase awareness in medical malpractices and deter health staff from malpractice.