A review of Morgagni and Bochdalek hernias in adults.

The incidence of Bochdalek and Morgagni hernias among adults is very rare. The purpose of this study was to determine retrospectively the prevalence and characteristics of adult Bochdalek and Morgagni hernias in a decade. Consequently, we demonstrated 12 patients with Bochdalek and 8 patients with Morgagni hernias. We presented plain radiography, operation images, and computed tomography findings of an adult patient with symptoms due to Bochdalek and Morgagni hernias. In surgical repair, the Morgagni hernia is best approached via laparotomy, and the Bochdalek hernia can be treated through thoracotomy or laparotomy.

Bochdalek hernia with concomitant partial situs inversus in an adult.

We report the case of 44-year-old woman with a left-sided Bochdalek hernia (BH) with concomitant partial situs inversus. The patient was presented from the outpatient clinic with lower chest discomfort. She had suffered from abdominal pain for one year, with no history of trauma, previous surgery, or extreme physical exertion. Chest radiograph revealed a large left-sided BH. The patient underwent thoracotomy. Intestinal organs, containing bowel, small intestine, caecum, and appendix were seen in the left hemithorax. Because of the failure to reduce the intestinal organs into the peritoneal cavity, laparotomy was performed. The right side of the abdominal cavity was empty. In conclusion, partial situs inversus was diagnosed. The diaphragmatic defect was repaired with non-absorbable sutures via laparotomy, and with a prolene mesh via thoracotomy. Bochdalek hernia with partial situs inversus is a rare clinical entity with none reported in medical literature.

The effects of intrathecal levobupivacaine and bupivacaine in the elderly.

The objective of this study was to compare the block durations and haemodynamic effects associated with intrathecal levobupivacaine or bupivacaine in elderly patients undergoing transurethral prostate surgery. Eighty patients were prospectively randomised to receive plain 1.5 ml levobupivacaine 0.5% (group levobupivacaine) or 1.5 ml plain bupivacaine 0.5% (group bupivacaine) in combination with fentanyl 0.3 ml (15 microg) for spinal anaesthesia. The time to reach T10 and peak sensory block level, and to maximum motor block were significantly shorter in group bupivacaine compared to group levobupivacaine (p < 0.05). Peak sensory block level was also significantly higher in group bupivacaine. In group bupivacaine, mean arterial pressure was significantly lower than group levobupivacaine, starting from 10 min until 30 min after injection (p < 0.05). Hypotension and nausea were less common in group levobupivacaine than group bupivacaine (p < 0.05). Because of the better haemodynamic stability and fewer side-effects associated with levobupivacaine, it may be preferred for spinal anaesthesia in elderly patients.

N-acetylcysteine prevents deleterious effects of ischemia/reperfusion injury on healing of colonic anastomosis in rats.

This study was designed to determine the effects of intraperitoneally or orally administered N-acetylcysteine (NAC) on wound healing following resection and anastomosis of a colon segment with ischemia/reperfusion injury. Forty female Sprague-Dawley rats were randomly allocated to one of four groups containing 10 rats each: (1) normal resection plus anastomosis; (2) ischemia/reperfusion plus resection plus anastomosis; (3) ischemia/reperfusion plus resection plus anastomosis plus intraperitoneal NAC; (4) ischemia/reperfusion plus resection plus anastomosis plus oral NAC. Group comparison showed that the anastomosis bursting pressure was significantly higher in group 3 than in the other groups. The mean tissue hydroxyproline concentration in the anastomotic tissue was significantly lower in group 2 than in the other groups. The collagen deposition was significantly increased on day 7 in groups 3 and 4 compared to the other groups. In conclusion, this study demonstrates that NAC significantly prevents the effects of reperfusion injury on colonic anastomoses in a rat model.

The independent risk factors of mortality and morbidity from upper gastrointestinal system haemorrhages after surgery.

BACKGROUND: The aim this study was to determine the variables influencing the morbidity and mortality of operated patients with upper gastrointestinal haemorrhage (UGIH) and to define the independent risk factors. PATIENTS AND METHODS: The medical records of 62 patients with upper gastrointestinal haemorrhage who underwent operation were reviewed for variables including age, gender, shock, association with co-morbidity, pulse rate, haemoglobin levels, white blood cell count, serum urea, creatinine, sodium and potassium level, time of operation, blood transfusion unit, Rockall risk score and the length of hospital stay. In order to determine the independent risk factors related to mortality and morbidity, we carried out logistic regression analysis. RESULTS: Morbidity and mortality rates were 35.4% (22 patients) and 29.1% (18 patients), respectively. The independent risk factors affecting morbidity were serum albumin level and Rockall score > or = 5, and the independent risk factors affecting mortality were advanced age, and high Rockall score. CONCLUSION: To decrease the postoperative morbidity and mortality rates in patients with UGIH requiring surgery, their pre-operative risk factors should be demonstrated. We believe that the establishment of interventional indication on time and the evaluation of the intra-operative surgical region and technique in combination with the patient- and disease-related factors would help reduce morbidity and mortality rates.

Evaluation of biochemical variables in patients with trigeminal neuralgia.

The aim of this study was to evaluate the calcium, sodium, potassium, serum iron, vitamin B12, and albumin concentrations, and alkaline phosphatase (ALP) activity, in samples of serum from patients with primary trigeminal neuralgia (TN), and investigate the associations between them. Results from 73 patients who had been diagnosed with primary TN between December 2015 and 2017 were compared with those of 70 healthy subjects. Calcium (p=0.013), iron (p=0.004), and albumin (p=0.001) concentrations in the primary TN group were significantly lower than those in the control group, whereas the ALP activity was significantly higher in the TN group than in the control group (p=0.007). However, there was no significant difference in the sodium, potassium, or vitamin B12 concentrations. Biochemical variables have a role in the pathogenesis and treatment of primary TN, but there are few studies that characterise the relations between the condition and the biochemical changes. Further studies are therefore necessary to gain more information.

Risk factors affecting morbidity in typhoid enteric perforation.

INTRODUCTION: Typhoid enteric perforation is a cause of high morbidity and mortality. This study aim is to determine the factors affecting morbidity in patients with typhoid enteric perforation. MATERIALS AND METHODS: Ninety-six patients with typhoid enteric perforation were reviewed. The variables are defined as follows: Age, gender, complaints, perforation-operation interval, typhoid fever treatment before the perforation or not, white blood cell (WBC) count, hemoglobin level (Hgb), intraoperative peritonitis intensity, the number of perforations, and type of surgery were examined. To determine the independent risk factors that might affect morbidity in typhoid enteric perforation, we made use of multivariate logistic regression analysis. RESULTS: Nine variables were applied the univariate analysis, which were greater than 30 years (P = 0.218), male gender (P = 0.02), preoperative treatment (P = 0.147), less than or equal to 48 h perforation-operation interval (P = 0.013), greater than 4,000 K/UL WBC (P = 0.388), less than 8 g/dL Hgb (P = 0.026), greater than 29 Mannheim Peritonitis Index (P < 0.0001), multiple perforation number (P = 0.614), and primary repair (P = 0.105). Logistic regression analysis showed that Mannheim Peritonitis Index (P = 0.014) and perforation-operation interval (P = 0.047) were defined as independent risk factors affecting morbidity. CONCLUSIONS: If liquid electrolyte, blood, antibiotics, and parenteral nutrition are applied in typhoid enteric perforation cases adequately, then severe peritonitis becomes an independent risk factor that affects morbidity. Early diagnosis and appropriate surgery type would decrease morbidity and mortality.

Asymptomatic thyroid tuberculosis in a multinodular goitre patient: a case report.

Thyroid tuberculosis is a very rare disease of the thyroid gland. In recent years, the incidence of extra-pulmonary tuberculosis has been showing a progressive increase. We present the case of a 41-year old female patient, operated for an asymptomatic multinodular goiter, and who had a histopathological diagnosis of thyroid tuberculosis. Thyroid tuberculosis should be kept in mind in the differential diagnosis of thyroid nodules, even in patients with no history and no symptom of tuberculosis disease.

Factors affecting morbidity and mortality in gangrenous cholecystitis.

INTRODUCTION: Gangrenous cholecystitis is a serious complication of acute cholecystitis. Male gender, older age, leukocytosis, cardio-vascular diseases and diabetes were reported as factors that increase the risk of gangrenous cholecystitis. The aim our study was to determine variables affecting morbidity and mortality as well as to define the independent risk factors in Gangrenous Cholecystitis. METHODS: Fifty three patients who had been treated for Gangrenous Cholecystitis were reviewed. The variables are defined as follows: age, gender, systemic diseases, Mannheim Peritonitis index, aspartate aminotransferase, alanine aminotransferase, white blood cell count and type of surgery. In order to determine the independent risk factors that might affect morbidity and mortality in Gangrenous Cholecystitis, we made use of multivariate logistic regression analysis. RESULTS: The independent risk factors affecting on morbidity were age (P = 0.037), existing systemic disease (P = 0.047) and > or = 29 Mannheim Peritonitis index (P = 0.008), and the independent risk factors affecting on mortality were age (P = 0.046), white blood cell count (P = 0.035). Pre-operative and post-operative third day aspartate amino-transferase and alanine aminotransferase average values were compared, there was a significant difference (P < 0.0001, P < 0.0001 respectively). CONCLUSIONS: We found that older age, > or = 29 Mannheim Peritonitis index and existence of systemic diseases were independent risk factors affecting morbidity. Older age and lower of white blood cell count were independent risk factors affecting mortality. We believe that further comprehensive studies, involving prospective, multi-center and a large number of patients, are needed.

Can diffusion weighted MRI differentiate between inflammatory-infectious and malignant pleural effusions?

AIM: To assess exudative pleural effusions with diffusion-weighted magnetic resonance imaging (DW-MRI) in order to determine non-invasive differentiation criteria for inflammatory-infectious and malignant effusions. MATERIALS AND METHODS: Thirty-two patients with pleural effusions underwent DW-MRI with 4 different b values (10, 500, 750 and 1000 s/mm2). ADC maps were generated automatically. Signal intensity and ADC values were measured. Following MRI, pleural fluid of 10-15 ml was obtained and analyzed. AUC values were compared for different diffusion levels of ADC and SI measurements. The relationship between ADC values and pleural effusion LDH and total protein levels was examined. RESULTS: The cut-off values obtained from signal intensity and ADC measurements to differentiate exudates with malignant pathology were not found to be statistically significant. In the inflammatory-infectious group, a significant negative correlation was observed between ADC values and pleural fluid LDH measurements in all b values. In the malignant group, a significant positive correlation was observed between ADC values and pleural fluid total protein measurements in b values of 500 and 1000. CONCLUSION: Infectious/inflammatory and malignant effusions overlap strongly and cannot therefore be differentiated using DW MRI.

Temporal evolution of the Seebeck coefficient in an ac driven strongly correlated quantum dot.

We study the response of the thermopower of a quantum dot in the Kondo regime to sinusoidal displacement of the dot energy level via a gate voltage using time dependent non-crossing approximation and linear response Onsager relations. Instantaneous thermopower begins to exhibit complex fluctuations when the driving amplitude is increased at constant driving frequency. We also find that the time averaged thermopower decreases steadily until it saturates at constant driving amplitude as a function of inverse driving frequency. On the other hand, time averaged thermopower is found to be quite sensitive to ambient temperature at all driving frequencies for large driving amplitudes. We discuss the underlying microscopic mechanism for these peculiarities based on the behaviour of the dot density of states.

Designer thermal switches: the effect of the contact material on instantaneous thermoelectric transport through a strongly interacting quantum dot.

We investigate the effect of contact material on the instantaneous thermoelectric response of a quantum dot pushed suddenly into the Kondo regime via a gate voltage using time dependent non-crossing approximation and linear response Onsager relations. We utilize graphene and metal contacts for this purpose. Instantaneous thermopower displays sinusoidal oscillations whose frequency is proportional to the energy separation between the van Hove singularity in the contact density of states and the Fermi level for both cases, regardless of the asymmetry factor at the onset of the Kondo timescale. The amplitude of the oscillations increases with decreasing temperature, saturating around the Kondo temperature. We also calculate the instantaneous figure of merit and show that the oscillations taking place at temperatures above the Kondo temperature are enhanced more than the ones occurring at lower temperatures due to the violation of the Wiedemann-Franz law. Graphene emerges as a more promising electrode candidate than ordinary metals in single electron devices since it can minimize these oscillations.

Splenic injuries: factors affecting the outcome of non-operative management.

PURPOSE: The aim of this study was to evaluate the outcome of non-operative management (NOM) in patients with splenic injuries and to determine the predictive factors of NOM failure. METHODS: Two hundred and six patients with splenic injury were admitted between January 2005 and April 2011. Of the 206 patients with splenic injury, 47 patients met the inclusion criteria of NOM. The mechanism of injury, grade of splenic injury, other intra- and extra-abdominal injuries, systolic blood pressure on admission, hemoglobin levels, number of transfusions, Injury Severity Score (ISS), Glasgow Coma Scale score, and hospitalization period were recorded. The patients were divided into two groups: those with NOM and those in whom the failure of NOM led to laparotomy. The patients were monitored for vital signs, abdominal findings, and laboratory data. NOM was abandoned in cases of hemodynamic instability, ongoing bleeding, or development of peritonitis. Independent predictive factors of NOM failure were identified. The patients managed non-operatively were compared with the patients for whom NOM failed. RESULTS: NOM was successful in 40 of 47 patients. There were differences between the two groups for ISS, hemoglobin levels, need for blood transfusion, and the number of associated extra-abdominal injuries. The grade of splenic injury was determined to be an important and significant independent predictive factor for the success of NOM of splenic injuries. CONCLUSIONS: The grade of splenic injury is an important and significant independent predictor factor for the success of NOM. NOM is not recommended in patients with high-grade splenic injury.

Bispectral index monitoring to guide end-tidal isoflurane concentration at three phases of operation in patients with end-stage liver disease undergoing orthotopic liver transplantation.

It has been shown that anesthetic requirements during liver transplantation are inversely proportional to the degree of hepatic dysfunction. We investigate alterations during the three phases of requirements for intraoperative isoflurane within the target of 40 to 55 Bispectral Index (BIS) values concerning patients with end-stage liver disease who are undergoing liver transplantation. After faculty ethics committee approval, we studied 50 patients of (age range, 18 to 65 years) who were undergoing liver transplantation. After induction, we used isoflurane with air/oxygen (FiO(2) = 0.5%) for anesthetic maintenance. The isoflurane concentration was set within the range of 40 to 55 BIS values. Remifentanil (0.15 µg/kg/min) was infused for analgesia and cisatracurium was administered via continuous infusion. After anesthetic induction, we inserted arterial, pulmonary artery, and central venous catheters. The heart rate, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), body temperature, BIS values, end-tidal isoflurane concentration (ETiso) and end-tidal carbon dioxide concentration (ETCO(2)) were recorded at 30-minute intervals during the dissection and neohepatic phases, at 15-minute intervals during the anhepatic phase. In addition, we calculated the cardiac index during the three phases. There was no difference in heart rates among the operative phases. In contrast, there were significant changes in MAP, MPAP, BIS, ETCO(2) and body temperature values. However, all of these parameters were in physiological ranges and clinically acceptable. The ETiso values were lowest in the anhepatic phase compared to other phases, but the differences were not clinically important. The ETiso values in the dissection and neohepatic phases were compared with the anhepatic phase higher 5% and 8.6% respectively. During liver transplantation, ETiso requirement for the anhepatic phase was lower compared with the other two phases within the range of 40 to 55 BIS values.

The effects of single-dose tramadol on post-operative pain and morphine requirements after coronary artery bypass surgery.

AIM: To investigate the effects of a single dose of tramadol administered prior to extubation on post-operative pain and morphine consumption after coronary artery bypass surgery. METHODS: Patients were randomized post-operatively into two groups (group T, n= 30; group P, n= 30). The technique of anaesthesia was standardized for all patients. The patients in group T received intravenous tramadol, 1 mg/kg, and the patients in group P received 2 ml of saline 0.9%, both approximately 1 h before extubation. After extubation, all patients were allowed to use the morphine patient-controlled analgesia (PCA) device for 24 h post-operatively. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anaesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated. RESULTS: In group P, the visual analogue scale (VAS) scores were found to be higher 30 min (P < 0.01), 1 h (P < 0.01), 2 h (P < 0.01) and 4 h (P < 0.05) after extubation. The patient comfort scores were higher in group T 30 min (P < 0.01), 1 h (P < 0.05), 2 h (P < 0.01) and 4 h (P < 0.01) after extubation. The total morphine consumption was higher in group P at all evaluation times (P < 0.01), and the numbers of PCA demands and boluses were also higher in group P (P < 0.01). CONCLUSIONS: The study demonstrated that a single dose of tramadol administered prior to extubation following coronary artery bypass surgery is associated with a decrease of up to 25% in morphine consumption, a decrease in the VAS scores and an improvement in patient comfort within the first 4 h post-operatively.

Relation between severity of injury and the early activation of interleukins in multiple-injured patients.

The aim of this study was to evaluate the relation between severity of injury and the early activation of interleukins in multiple-injured patients. Ninety-nine patients with multiple injuries were included in this prospective study. Plasma levels of interleukin (IL)-1, IL-2, IL-6, IL-8 and TNF-alpha were measured. Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Score (GCS) and the Acute Physiology and Chronic Health Evaluation II (APACHE-II) were all recorded. Of the 99 patients, 82 were male and 17 were female. The mean age was 26.6+/-20.7 years. The mortality rate for this series was 17%. Patients who died from trauma exhibited a significant increase for IL-2, IL-6 and IL-8 in comparison with patients who survived. Significant differences for ISS, RTS and GCS were found between survivors and non-survivors. Values in all patients with ISS>16 were increased and these increases were significant for IL-6 and IL-2. These data show that the initial increase of IL-2, IL-6 and IL-8 might predict the patients with a high possibility of mortality and a significant increase of IL-2 and IL-6 in patients with ISS>16 might be used in a new developed trauma score combined with ISS as an indicator for the injury severity.

Oral clonidine premedication does not reduce postoperative vomiting in children undergoing strabismus surgery.

BACKGROUND: We evaluated the effect of oral clonidine on postoperative vomiting (POV) in children undergoing strabismus surgery. METHODS: Eighty ASA physical status I children aged 3-12 years were randomly assigned to one of two groups in a double-blinded manner. One hour before surgery, each patient in the clonidine group (n=40) received clonidine 4 micro g kg-1 in apple juice 0.2 ml kg-1, and each of the controls (n=40) received apple juice 0.2 ml kg-1 only. The protocol for general anesthesia was propofol-sevoflurane in N2O/O2. A paracetamol suppository was administered in each case to prevent postoperative pain. Patient responses during 0-48 h after anesthesia were recorded as complete (no POV, no antiemetic rescue required), retching, vomiting, or rescue antiemetic. RESULTS: There were no significant differences between the clonidine and control groups regarding the number of patients with complete response (21 vs. 18, respectively) retching (10 vs. 14, respectively), vomiting (19 vs. 22, respectively), or rescue antiemetic (9 vs. 12, respectively) during the first 48 h. CONCLUSION: Oral premedication with clonidine 4 micro g kg-1 did not reduce the rate of POV in the children undergoing strabismus surgery.

Cervical subcutaneous emphysema: an unusual complication of adenotonsillectomy.

Removal of the tonsils and adenoid tissue because of recurrent infection and/or respiratory obstruction is one of the most commonly performed operations. A rare complication during this intervention is subcutaneous surgical emphysema. The awareness of anaesthesiologists and otolaryngological surgeons will protect the patient from serious consequences. We report our experience with this complication and provide a review of the literature.