The relationship between the level of lesion and progression in Reimer's index of spina bifida patients.

AIM: We aimed to evaluate the influence of the lesion level and acetabular displasia on the progression of hip dislocation in patients with spina bifida. MATERIAL AND METHOD: Two hundred twelve hips of 106 cases with spina bifida were evaluated both clinically and radiologically. Their vertebral level of lesions, clinical examinations, radiological migration index, and acetabulum terms were noted and were evaluated in terms of their relations with the level of lesion-migration and dysplasia. Data analysis method was evaluated using SPSS 22.0 program. RESULTS: Deficiency of acetabulum was present in 33 % of the cases with spina bifida. Dysplastic floor was found to be as equally important as the level of lesion in the progression of hip dislocation (p = 0.002). Progression and dislocation incidences were observed to be higher in the thoracic level (p = 0.008). Reimer's progression index was seen to be a reliable way of assesment. CONCLUSION: The development of hip dislocation and progression are not solely connected with muscle imbalance. Encountered more frequently in these cases, acetabular dysplasia is a factor that is as important as the level of lesion in the formation of hip dislocation and progression. Hip dislocation is associated with more progression in the higher level lesions. Reimer's index is a reliable assessment criteria.

Incidence and type of foot deformities in patients with spina bifida according to level of lesion.

AIM: The previously suggested association between the incidence of high-level foot deformity and muscle imbalance is no longer supported, when evaluated independent from motor and sensory loss and level of lesion, by current studies. The purpose of this study was to evaluate the association between level of lesion and foot deformity. METHODS: Of 545 patients, a total of 136 (272 feet) patients admitted to the spina bifida clinic between 2010 and 2014 were included in this study. Levels of all lesions were evaluated using initial operation data, the motor-sensory exams, and direct radiography. All patients were categorized into four different groups: Thoracic region (group 1), high-level lumbar-L1-2 region (group 2), mild and lower lumbar regions (L3-4-5) (group 3), and Sacral region (group 4). RESULTS: The mean follow-up time was 34.9 months (range 8-176 months). Group 1, group 2, group 3, and group 4 included 24 (17.6%), 14 (10.3%), 19 (14%), and 79 (58.1%) patients with regards to level of lesion, respectively. The incidences of foot deformity were 85.4, 85.7, 81.5, and 50.6% in groups 1, 2, 3, and 4, respectively. Of all patients, 22% (61 feet) had clubfoot, 16% (44 feet) pes cavus, 10% (26 feet) pes valgus, 6% (17 feet) isolated equinus, 6 % (17 feet) pes calcaneus, and 5% (13 feet) metatarsus adductus. Patients without a foot deformity (81% of normal feet) usually had a lesion at the sacral level (p ≤ 0.05). On the other hand, isolated equinus (70%) and clubfoot (49%) deformities were mostly observed in spinal lesions (p > 0.05). The incidence of pes calcaneus, pes valgus, and adductus deformities inclined as the lesion level decreased (p > 0.05). CONCLUSION: In this study, it was concluded that foot deformities were directly related to the level of lesion. The comparison of higher and lower level lesions revealed that the types of foot deformity differed significantly. The muscle imbalance due to spina bifida was not sufficient to explain the pathology. On the other hand, the level of spinal lesion is an important factor for the type of deformity.

Telbivudine in liver transplant recipients: Renal protection does not overcome the risk of polyneuropathy and myopathy.

The recently reported benefit of telbivudine for renal function has not been systematically studied in long-term liver transplantation (LT) recipients who are at high risk for renal impairment. We aimed to examine whether switching lamivudine therapy to telbivudine could improve renal function in LT recipients who have impaired renal function. This single-center, prospective cohort study enrolled LT recipients who were on lamivudine for hepatitis B virus (HBV) prophylaxis and who had renal impairment for at least 1 year. Lamivudine was switched to telbivudine. The primary outcome was to evaluate the change in renal function at weeks 12, 24, 36, and 48. The secondary outcomes were to assess the efficacy of telbivudine for HBV prophylaxis and the safety profile of telbivudine in the posttransplant setting. After 45 patients were enrolled, the study was terminated early because of increased rates of polyneuropathy/myopathy. During telbivudine treatment (median, 64 weeks), estimated glomerular filtration rate (eGFR) increased in 34 patients (76%). The improvement in renal function was prominent after 24 weeks of telbivudine treatment. Telbivudine was effective as prophylaxis against HBV recurrence. Twenty-six patients (58%) developed polyneuropathy and/or myopathy. The 1-year estimated incidence of polyneuropathy/myopathy was 28%. Diabetes was the strongest predictor of polyneuropathy/myopathy (hazard ratio, 4.13; 95% confidence interval, 1.49-11.50; P = 0.007). In conclusion, although it seems to have a favorable effect in the improvement of renal function and seems to be effective in the prevention of HBV recurrence, the high risk of polyneuropathy and myopathy hampers the use of telbivudine in LT recipients.

Acquired right diaphragmatic hernia following pediatric living donor orthotopic liver transplantation.

ADH following OLT is a rare entity. Herein, we report a case of Alagille syndrome who developed ADH secondary to OLT, and possible etiological causes are discussed in light of the literature.

Long-term outcome of kidney transplantation from elderly living and expanded criteria deceased donors.

The imbalance between organ demand and supply causes the increasing use of suboptimal donors. The aim of this study is to investigate the survival and allograft function of kidney transplantation from standard (SLD) and elderly living (ELD), standard criteria (SCDD) and expanded criteria deceased (ECDD) donors. All patients transplanted from 1997 to 2005 were investigated according to the donor characteristics. Data were collected retrospectively during the 83.4±43.1 months of follow-up period. ELD was defined as donor age≥60 years. ECDD was defined as UNOS criteria. A total of 458 patients were divided into four groups: SLD (n:191), ELD (n:67), SCDD (n:154), and ECDD (n:46). Seven-year death-censored graft survival in SLD, ELD, SCDD, and ECDD were 81.6%, 64.8%, 84.7%, and 68.3%, respectively (p=0.003). The death-censored graft survival in ELD group was lower than in SLD (p=0.007) and SCDD (p=0.007) groups, while in ECDD group it was lower than in SCDD group (p=0.026). Patient survival was similar. In ECDD group, 83% of total deaths occurred within the first 3 years, mainly due to infections (66.6%) (p<0.05). Estimated glomerular filtration rate (eGFR) was lower in ELD (compared with SLD and SCDD); and ECDD (compared with SCDD) at last visit. In multivariate analysis, ELD, experience of an acute rejection episode and presence of delayed graft function were the independent predictors for death censored graft loss. Transplantation of a suboptimal kidney provides inferior graft survival and function. A higher number of deaths due to infection in the early post-transplant period in the ECDD group are noteworthy.

Characteristics of femoral neck fractures in osteogenesis imperfecta: Series of four-teen consecutive hips in twelve patients.

INTRODUCTION: While long bone fractures are commonly seen in individuals with Osteogenesis Imperfecta (OI), femoral neck fractures (FNF) are exceedingly rare. There is a lack of comprehensive data regarding the etiology of FNFs, their characteristics, and the treatment protocols. Our aim was to determine the characteristics of femoral neck fractures in children with OI. MATERIALS AND METHODS: This study was conducted as retrospective series covering period of January 2011-December 2022. Total of 14 femoral neck fractures in 12 patients were included into final analysis. Age, gender, fracture location, ambulation level, injury mechanism, Sillence type, pre-fracture collo-diaphyseal angle, presence of previous implants and applied treatments were noted. RESULTS: The mean age was 9.3 (range: 3-16), 8 out of 12 patients were males. Sillence type 3 OI was most common (50 %) type. Among 12 patients, 2 (16.6 %) were restricted ambulatory while 5 (41.6 %) were non-ambulatory. Seven patients had prior femoral implants. Six fractures were managed non-operatively, while others underwent surgery, with cannulated screws (42.8 %) or plate osteosynthesis (7.1 %). All eight cases (100 %) with minor trauma or unknown origin were Sillence type 3-4, displaying varus deformity. FNFs that occured in mobile patients required higher-energy traumas. CONCLUSION: Femoral neck fractures in OI showed differing trauma mechanisms in ambulatory vs. non-ambulatory patients. Non-surgical treatment may be considered with in patients with high-risk anesthesia concerns, requiring higher level clinical studies.

Glasgow coma scale and APACHE-II scores affect the liver transplantation outcomes in patients with acute liver failure.

BACKGROUND: The timing and selection of patients for liver transplantation in acute liver failure are great challenges. This study aimed to investigate the effect of Glasgow coma scale (GCS) and APACHE-II scores on liver transplantation outcomes in patients with acute liver failure. METHOD: A total of 25 patients with acute liver failure were retrospectively analyzed according to age, etiology, time to transplantation, coma scores, complications and mortality. RESULTS: Eighteen patients received transplants from live donors and 7 had cadaveric whole liver transplants. The mean duration of follow-up after liver transplantation was 39.86+/-40.23 months. Seven patients died within the perioperative period and the 1-, 3-, 5-year survival rates of the patients were 72%, 72% and 60%, respectively. The parameters evaluated for the perioperative deaths versus alive were as follows: the mean age of the patients was 33.71 vs 28 years, MELD score was 40 vs 32.66, GCS was 5.57 vs 10.16, APACHE-II score was 23 vs 18.11, serum sodium level was 138.57 vs 138.44 mmol/L, mean waiting time before the operation was 12 vs 5.16 days. Low GCS, high APACHE-II score and longer waiting time before the operation (P<0.01) were found as statistically significant factors for perioperative mortality. CONCLUSION: Lower GCS and higher APACHE-II scores are related to poor outcomes in patients with acute liver failure after liver transplantation.

A New Perspective on the Diagnosis of Septic Arthritis: High-Resolution Thermal Imaging.

AIMS: An increase in temperature in an area suspected of septic arthritis is a clinically important finding. The aim of this study is to evaluate temperature changes in septic arthritis with a high-resolution thermal camera. METHODS: A total of 49 patients, who were evaluated with a prediagnosis of arthritis (septic or non-septic), were included in this study. A temperature increase in the knee with suspected septic arthritis was evaluated by using thermal imaging and compared with the opposite-side joint. Then, in order to confirm the diagnosis, a culture was taken using routine intra-articular aspiration. RESULTS: The thermal measurements were compared in 15 patients with septic arthritis and 34 patients with non-septic arthritis. The mean temperature was 37.93 °C in the septic group, while it was 36.79 °C in the non-septic group (p < 0.000 *). The mean temperature difference in both joints was 3.40 °C in the septic group, while it was 0.94 °C in the non-septic group (p < 0.000 *). While the mean temperature was 37.10 °C in the group with septic arthritis, it was measured to be 35.89 °C in the group non-septic arthritis (p < 0.020). A very strong positive correlation was found between the difference in the mean temperatures of both groups and the values of the hottest and coldest points (r = 0.960, r = 0.902). CONCLUSIONS: In the diagnosis of septic arthritis, thermal imagers can be used as a non-invasive diagnostic tool. A quantitative value can be obtained to indicate to a local temperature increase. In future studies, specially designed thermal devices can be developed for septic arthritis.

Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy.

PURPOSE: This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia. METHODS: Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time. RESULTS: Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures. CONCLUSIONS: As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases. LEVEL OF EVIDENCE: III.

One-year prospective analysis of hand and forearm injuries in children.

The primary aim of this study was to assess the epidemiological evaluation of acute pediatric hand injuries frequently encountered in emergency department units. Its secondary aim was to identify the risk factors associated with such injuries. Out of the 1547 acute hand and forearm injury cases admitted to emergency trauma department between March 2017 and March 2018, the 129 injuries pertaining to children were included in the study. Mechanism, time, etiology, injured structures, anatomical regions, cut structures, and occupational accident status were determined in addition to demographic information. The injuries were evaluated according to circadian rhythm in order to ascertain the hours of intensification. The Modified Hand Injury Severity Score (MHISS) was used to assess injury severity. The mean age of 129 patients was 10.1 years. The most injuries were observed in the groups of patients over 12 years of age (57, 44%), and 0-6 years of age (42, 32%), respectively. Nineteen students participating in vocational internships were injured (14%). Twenty-six cases (20%) in the 12-year-old group involved punching glass, and 34 (26%) cases in the 0-6 age groups involved fingertip crush injuries. Temporal injury intensity was seen to have increased between 12.00 and 19.00 hours. The mean MHISS was 41 (8-120). Injury prevention measures need to be increased, particularly for fingertip injuries. A specific injury severity assessment system is also required for pediatric hand injuries, which are often simpler and easier to treat than adult hand injuries. Additionally, training and increasing awareness are believed to be important steps in preventing pediatric hand injuries.

Single-incision laparoscopic cholecystectomy: is it more than a challenge?

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a promising technique with regard to reducing postoperative pain, decreasing complications, and improving cosmesis. METHODS: Between September 2008 and April 2009, 20 patients underwent cholecystectomy via SILS. The umblicus was the access point of entry to the abdomen for all the patients. RESULTS: Of the 20 cholecystectomies, 19 were performed with SILS. Failure of trocar insertion was the reason for conversion with the first patient. No complications or mortalities were associated with the technique. The mean operating time was 94 min. CONCLUSION: The use of SILS for cholecystectomy is safe and feasible with reasonable operation times.

Gastric remnant cancer: an old problem with novel concerns.

BACKGROUND AND AIMS: The patients with cancers in the remnant stomachs after previous partial resections for benign diseases constitute a peculiar subset of the patients with gastric cancer. They are generally at advanced stages on admissions due to disregarding the symptoms related to cancer. PATIENTS AND METHODS: Twenty six patients with cancer arising from the remnant stomach were analyzed. Clinicopathologic features such as age, gender, time interval between the initial operation and diagnosis of gastric remnant cancer, preoperative symptoms, surgical management, and tumor characteristics like size, location, histopathology, depth of invasion, lymph node involvement, presence of distant metastasis, and stages were documented. RESULTS: None of the cancers were diagnosed by routine surveillance and all the patients were symptomatic at the time of diagnosis. Twenty five patients were qualified for surgery. The resectability rate was 61% (n = 16). The ability to perform a curative resection and tumor location at the anastomotic site were determined as the factors significantly influencing survival (p < 0.05). CONCLUSION: Curative resection has to be the goal of surgical management in patients with gastric remnant cancer. Concerning clinician should be sceptical about a newly developing cancer in order to detect it in an early stage and enhance resectability.

Inter-individual and inter-organ variability in the bioactivation of paracetamol by human liver and kidney tissues.

Paracetamol (PAR) overdose is associated with massive hepatic injury; it may induce kidney toxicity as well. It is essential to measure organ-specific activities of related CYPs for evaluating the overdose cases. Available HPLC-based methods require high amounts of tissue samples. In order to develop liquid chromatography mass spectrometry (LC-MS)-based methods to process small amounts of human tissues, liver and kidney samples were obtained. Individual microsomes were prepared and incubated with PAR (for quantifying bioactivation), with nifedipine (for measuring CYP3A4 activity) and with p-nitrophenol (for measuring CYP2E1 activity). The small amount of tissue microsomes was sufficient to measure both the formation of NAPQI and the activities of CYP enzymes. Although the sample size in group was relatively low, both NAPQI formation and activity of CYP2E1 were significantly higher in males compared to females in kidney. Considerable variations in the metabolic capacity of individuals were observed for both organs.

Neuroprotective Effects of C-terminal Domain of Tetanus Toxin on Rat Brain Against Motorneuron Damages After Experimental Spinal Cord Injury.

STUDY DESIGN: Experimental animal study investigating the efficacy of C-terminal domain of tetanus toxin application as neuroprotective effects on rat brain in a model of spinal cord injury (SCI). OBJECTIVE: The aim of the present study was to investigate the possible role of C-terminal domain of tetanus toxin (Hc-TeTx) on cell death mechanisms including apoptosis and autophagy following SCI. SUMMARY OF BACKGROUND DATA: Traumatic SCI can lead to posttraumatic inflammation, oxidative stress, motor neuron apoptosis, necrosis, and autophagy of tissue. To promote and enhance recovery after SCI, recent development of devices and therapeutic interventions are needed. METHODS: Twenty-eight adult rats were divided into four groups (n = 7 each) as follows: sham, trauma (SCI), SCI + Hc-TeTx, and SCI + methylprednisolone groups. The functional neurological deficits due to the SCI were assessed by behavioral analysis using the Basso, Beattie and Bresnahan (BBB) open-field locomotor test. The alterations in pro-/anti-apoptotic and autophagy related-protein levels were measured by Western blotting technique. RESULTS: In this study, Hc-TeTx promotes locomotor recovery and motor neuron survival of SCI rats. Hc-TeTx also decreased expression of bax, bad, bak, cleaved caspase-3, Ask1, and autophagy-related proteins including Atg5 and LC3II in brain. Our study provides an evidence that cell death mechanisms play critical roles in SCI and that the nontoxic peptides including Hc-TeTx may exert protective effect and decrease cell death following SCI. CONCLUSION: Our preliminary findings suggest a possible therapeutic agent to improve survival after spinal cord trauma, but further analysis are still needed to evaluate the difference between acute and chronic injuries. LEVEL OF EVIDENCE: N/A.

Epidermal growth factor regulates apoptosis and oxidative stress in a rat model of spinal cord injury.

Spinal cord injury (SCI) leads to vascular damage and disruption of blood-spinal cord barrier which participates in secondary nerve injury. Epidermal growth factor (EGF) is an endogenous protein which regulates cell proliferation, growth and differention. Previous studies reported that EGF exerts neuroprotective effect in spinal cord after SCI. However, the molecular mechanisms underlying EGF-mediated protection in different regions of nervous system have not shown yet. In this study, we aimed to examine possible anti-apoptotic and protective roles of EGF not only in spinal cord but also in brain following SCI. Twenty-eight adult rats were divided into four groups of seven animals each as follows: sham, trauma (SCI), SCI + EGF and SCI + methylprednisolone (MP) groups. The functional neurological deficits due to the SCI were assessed by behavioral analysis using the Basso, Beattie and Bresnahan (BBB) open-field locomotor test. The alterations in pro-/anti-apoptotic protein levels and antioxidant enzyme activities were measured in spinal cord and frontal cortex. In our study, EGF promoted locomotor recovery and motor neuron survival of SCI rats. EGF treatment significantly decreased Bax and increased Bcl-2 protein expressions both in spinal cord and brain when compared to SCI group. Moreover, antioxidant enzyme activities including catalase, superoxide dismutase (SOD) and glutathione peroxidase (GPx) were increased following EGF treatment similar to MP treatment. Our experiment also suggests that alteration of the ratio of Bcl-2 to Bax may result from decreased apoptosis following EGF treatment. As a conclusion, these results show, for the first time, that administration of EGF exerts its protection via regulating apoptotic and oxidative pathways in response to spinal cord injury in different regions of central nervous system.

Effects of ropivacaine on pain after laparoscopic cholecystectomy: a prospective, randomized study.

Postoperative pain after laparoscopic cholecystectomy is an ongoing problem. To relieve this pain, practitioners have used many anesthetic and analgesic drugs. This study was undertaken to assess the effects of incisional and intraperitoneal administration of ropivacaine on postoperative pain and stress response in patients undergoing laparoscopic cholecystectomy. In this prospective, single-blinded, randomized study, 45 patients with ASA (American Society of Anesthesiologists) scores I and II who were about to undergo laparoscopic cholecystectomy were divided into 3 groups. After cholecystectomy, a total of 40 mL of 3.75% ropivacaine was administered pre-incisionally and intraperitoneally to patients in group 1 (n=14); pre-incisionally and intraperitoneally to patients in group 2 (n=17); and intraperitoneally and locally at incision sites to patients in group 3 (n=14). Blood levels of epinephrine and norepinephrine were examined preoperatively, 15 min after insufflation, and at the end of the operation. Visual analog pain scale scores and analgesic requirements were used for 24-h postoperative follow-up of pain levels reported by patients. No statistically significant difference was found among the 3 groups with respect to visual analog pain scale scores, total analgesic requirements, and accompanying pain, nausea, and vomiting. The earliest analgesic requirements were seen in group 2 (P<.005), and less shoulder pain was noted in group 3 (P<.005). Norepinephrine and epinephrine levels showed no statistically significant differences between the 3 groups. Administration of ropivacaine preoperatively and postoperatively for laparoscopic cholecystectomy has similar effects on postoperative pain and the stress response of patients.

Laparoscopic cholecystectomy in a patient with situs inversus totalis.

Currently, laparoscopic cholecystectomy is an undoubtfully optimal treatment of cholelithiasis. What about performing this procedure on a patient with situs inversus totalis and what are the difficulties of this operation for a right-handed surgeon? We presented a 35-year-old man with unknown situs inversus totalis who was admitted with epigastric pain and digestive problems. Ultrasonography and computed tomography of the abdomen confirmed the diagnosis of a gallstone. Besides, the liver and gallbladder were on the left side and the spleen was on the right. All systems were left-right reversal as mirror image in all diagnostic studies. Laparoscopic cholecystectomy was safely performed, despite of difficulties of situs inversus. The patient was discharged on postoperative day 1. It should be considered that existence of other anomalies may easily cause uninvited injuries. In the patients with situs inversus, laparoscopic cholecystectomy can be safely managed by an experienced surgeon through laparoscopy, and also hepatobiliary surgery.

Escobar (multiple pterygium) syndrome: Multidisciplinary approach to a very rare syndrome.

Escobar (multiple pterygium) syndrome is progressive and a very rare syndrome. It is generally characterized by multiple pterygia that are found in the cervical, antecubital and popliteal regions. In this report, we present the treatment management of a 14-year-old case with late stage Escobar syndrome who was admitted due to multiple pterygia and bilateral knee contractures. The treatment of this case was conducted in collaboration with the department of orthopedics and the department of physical therapy. The treatment of the case was done in three stages: soft tissue procedures, femoral recurvatum osteotomy and triple arthrodesis, respectively. In addition to all these, the patient did intensive physical therapy for one year. As a result of the operations and physical therapy, adequate muscle strength was obtained.

A horseshoe kidney from a live donor as a renal transplant: case report.

OBJECTIVES: This case report presents our experience regarding a horseshoe kidney from live donor to be used as a renal transplant. MATERIALS AND METHODS: The recipient was a 48-year-old man with chronic renal failure owing to hypertension who had been on hemodialysis for 2 years. The donor was his 43-year-old sister who had an uncomplicated horseshoe kidney with negative results on a urinalysis. An aortogram showed that the arterial supply to the kidney consisted of 2 superior arteries (1 on each side) and 1 inferior accessory artery that was divided to feed the lower fused parenchyma of the kidney. RESULTS: Surgery was performed via a retroperitoneal lumbotomy incision; the left half of the kidney was mobilized. The left kidney was procured by clamping the inferior accessory renal artery, transecting the parenchyma within the demarcation boundary. The transplant kidney was placed in the recipient's contralateral iliac fossa. The graft vein was anastomosed to the recipient's external iliac vein, the artery to the external iliac artery, and the ureter to the bladder. After perfusing the graft, no urine leakage was detected from the transacted surfaces, and the graft began producing urine. There were no complications after surgery. The patient was discharged on the 10th day after surgery with a creatinine level of 0.07 µmol/L. Maintenance immunosuppressive treatment included tacrolimus, mycophenolate mofetil, and prednisolone. CONCLUSIONS: We believe using a horseshoe kidney as a renal allograft after a detailed preoperative evaluation may help expand the donor pool.