The effect of pharyngeal structures on the severity of obstructive sleep apnea.

BACKGROUND/OBJECTIVE: Obstructive sleep apnea (OSA) is characterized by complete or partial cessation of breathing during sleep. The tongue is suggested as a possible anatomical site causing airway obstruction. However, the role of other pharyngeal structures in the development of OSA remains unclear. We designed a study using both the apnea-hypopnea index (AHI) and the oxygen saturation measurements to assess the severity of OSA. We aimed to identify critical anatomical structures of the upper airway that correlate with the severity of OSA and to evaluate the utility of magnetic resonance imaging (MRI) markers to detect possible OSA in patients without overt symptoms. MATERIALS AND METHODS: The study included participants referred to the neurology outpatient clinic from the check-up unit. Participants were grouped as controls, mild, moderate, or severe OSA according to the AHI. A cranial MRI with a field of view (FOV) encompassing the upper airway structures was obtained from all participants. The areas of the tongue and the uvula were measured on the sagittal images by drawing the boundaries of the tissues manually. The posterior air space (PAS) area was evaluated from regions of interest in five parallel planes. RESULTS: Of 105 participants, 30 were controls, 27 had mild, 25 had moderate, and 23 had severe OSA. The moderate and severe OSA groups did not differ in oxygen saturation levels during sleep. Therefore, patients with moderate and severe OSA were combined into one group (moderate/severe OSA). The area of the tongue was significantly larger in the moderate/severe OSA group compared to the control group. Both the tongue and the uvula areas showed a significant positive correlation with the AHI. CONCLUSION: Our findings suggest that the tongue and uvula have prominent roles in the severity of OSAS. It may be useful to measure these structures with MRI to screen for at-risk individuals without overt OSA symptoms.

Picnic, Accident or Cookies? A Systematic Approach to Guide the Selection of the Picture Definition Tasks in Linguistic Assessment.

OBJECTIVE: Picture description tasks are used to elicit language samples in individuals with aphasia and other cognitive disorders. However, task selection may affect the type of language variables elicited. In this study, our goal is to compare the strengths and the weaknesses of the two internationally used picture description tasks with a novel picture description task developed specifically for Turkish-speaking individuals. MATERIALS AND METHODS: In sum, 20 cognitively healthy individuals with a mean age of 52 ± 14/3 were included. Three different picture description tasks composed of single pictures were used: The Picnic Scene from the Western Aphasia Battery-Revised, the Cookie Theft picture from the Boston Diagnostic Aphasia Examination and the Accident Scene from the Turkish Language Assessment Test for Aphasia. All language samples were recorded using a digital voice recorder. Automated and semi-automated approaches were used for the systematic analysis of the language features that were classified into four levels: general language measures, the morphosyntactic level, the lexicosemantic level and the sentence level. RESULTS: Participants showed greater efficiency and produced the greatest number of subordinate clauses, derivational suffixes, passive voice suffixes and relative past tense construction during the Accident Scene description. On the lexicosemantic level, the Picnic Scene was particularly superior to the Cookie Theft Picture in eliciting nouns. Imperfective aspect use was less frequent in the Accident Scene description. CONCLUSION: All three tasks had limitations and advantages compared with each other. We recommend the development of novel picture description tasks that would be more effective in eliciting specific language features in Turkish-speaking individuals.

Neuropsychiatric outcomes and caregiver distress in primary progressive aphasia.

BACKGROUND: In this study, we aimed to outline the neuropsychiatric consequences of primary progressive aphasia (PPA) and to understand how neuropsychiatric symptomatology affects distress in caregivers. METHODS: The Neuropsychiatric Inventory (NPI) including the distress index (NPI-Distress) was used. Additional information about the caregiver burden was obtained using Zarit Burden Interview (ZBI). NPI, NPI-Distress, and ZBI data from 17 patients with a clinical diagnosis of PPA were compared with 10 stroke aphasia patients. Neuropsychiatric symptomatology was investigated based on three clusters; Mood, Frontal/Comportmental, and Psychotic/Disruptive. Additionally, the Activities of Daily Living Questionnaire (ADLQ) was used to outline the functional impairment. Twelve healthy controls were included to compare the neurocognitive test scores with PPA and stroke aphasia groups. RESULTS: A greater number of neuropsychiatric symptoms were observed in the PPA group compared to the stroke aphasia group. The number of symptoms in Mood, and Frontal/Comportmental clusters were greater than the number of symptoms in Psychotic/Disruptive clusters in the PPA group, whereas no significant relationship between the number of symptoms and symptom clusters was found in the stroke aphasia group. In the PPA group, a strong correlation was found between the NPI-Frequency × Severity scores and the NPI-Distress scores. Moreover, the NPI-Distress scores in the PPA group strongly correlated with the ZBI scores. Scores for anxiety, irritability/lability, and apathy had a stronger correlation with the NPI-Distress scores compared to the other NPI symptoms. The Communication subscale was the most impaired domain in the PPA group. Travel, and Employment and Recreation subscales showed greater functional impairment in the stroke aphasia group compared to the PPA group. CONCLUSIONS: Neuropsychiatric symptoms in PPA in our study were more frequent than previously reported. Furthermore, the distress index of the NPI was not only correlated with the severity of the neuropsychiatric symptoms but also reflected the overall burden on the caregivers in the PPA group.

Tourniquet Use Does Not Affect Pain and Function after Total Knee Arthroplasty: Patient Evaluation According to Pain Threshold.

We evaluated the effect of using a tourniquet on early-stage pain and 1-year postoperative functional outcomes when patients were divided into two groups according to the pain threshold (PT). Overall, 120 patients who were assessed preoperatively with an algometer were recruited for this prospective, double-blinded, randomized controlled trial. Patients were randomized to undergo total knee arthroplasty (TKA) with a tourniquet (group 1, 60 patients) and without tourniquet (group 2, 60 patients). Primary outcome measures were visual analog scale (VAS) pain scores at 24, 36, and 48 hours postoperatively and functional assessment with Knee Society Score (KSS) test at 1 year postoperatively. No significant differences were observed between groups in terms of gender (49 females and 8 males in group 1 vs. 53 females and 6 males in group 2; p = 0.201) and age (68.9 years in group 1 vs. 68.7 years in group 2; p = 0.811). There was no significant difference between groups in all the VAS and KSS 1 and KSS 2 scores. PT measurements ranged from 2.5 to 11.5 with a mean of 7.69 ± 1.70 and a median of 8. Total 54 patients with a median value of < 8 were defined as the low-PT group, and 62 patients with a median value of ≥ 8 were defined as the high-PT group. When the groups were evaluated according to using the tourniquet, 21 patients were operated on with a tourniquet and 33 patients without it in the low-PT group, while 36 patients were operated on with a tourniquet and 26 patients without it in the high-PT group. There was no significant difference in pain or functional scores between patients when comparing with-tourniquet and without-tourniquet or when comparing the low- and high-PT groups. This showed that the use of a tourniquet during TKA was not associated with either early-stage pain or 1-year postoperative functional outcomes according to algometer evaluation.Level of evidence: Level 1 prospective randomized study.

Eye movements as a measure of word comprehension deficits in primary progressive aphasia.

INTRODUCTION: Eye movement studies can uncover subtle aspects of language processing impairment in individuals with primary progressive aphasia (PPA), who may have difficulty understanding words. This study examined eye movement patterns on a word-object matching task in response to varying levels of word-knowledge in PPA. METHODS: Participants with semantic and non-semantic PPA completed an object-matching task, where a word was presented and participants then selected the corresponding pictured object from an array. Afterwards, participants defined words for trials to which they incorrectly pointed. Linear mixed-effects analyses examined fixation differences on targets and related and unrelated foils. RESULTS: On incorrectly-pointed trials, participants demonstrated greater fixation duration on related foils, demonstrating intra-category blurring. For words that could not be defined, there was similar fixation duration on related and unrelated foils, demonstrating inter-category semantic blurring. DISCUSSION: This study demonstrated that fixation patterns reflect varying levels of word knowledge in PPA.

Verbal and Nonverbal Memory in Neurodegenerative and Stroke Aphasia: Evidence From the Turkish Version of the Three Words Three Shapes Test.

BACKGROUND: Although language impairment is the most salient feature of cognitive impairment in both primary progressive aphasia (PPA) and stroke aphasia (SA), memory can also be impaired in both patient populations. OBJECTIVE: To identify distinctive features of verbal and nonverbal memory processing in individuals with PPA and those with SA. METHOD: We gave individuals with PPA (n = 14), those with SA (n = 8), and healthy controls (HC; n = 13) a comprehensive neuropsychological test battery and the Turkish version of the Three Words Three Shapes Test (3W3S-Turkish). The 3W3S-Turkish Test includes five subtests: Copy, Incidental Recall, Acquisition, Delayed Recall, and Recognition. High-resolution brain scans were performed in a subset of individuals with PPA and those with SA. Lesion distribution was limited to the dorsal language areas in the SA group, whereas peak atrophy areas in the PPA group extended beyond the language network, including the medial temporal lobe, precuneus, and posterior/medial portions of the cingulate cortex. RESULTS: Both the PPA and SA groups showed impairment in incidental recall, and the PPA group showed additional impairment in delayed recall. Greater impairment for verbal stimuli suggestive of material-specific memory impairment was evident in the PPA group's scores on the Incidental Recall and Delayed Recall subtests. Both aphasia groups retained the acquired information regardless of material type. CONCLUSION: Although both aphasia groups shared similarities in the involvement of the dorsal prefrontal working memory/attention network, the PPA group showed greater impairment in delayed recall compared with the SA group.

Utility of the Repeat and Point Test for Subtyping Patients With Primary Progressive Aphasia.

BACKGROUND: Primary progressive aphasia (PPA) may present with three distinct clinical sybtypes: semantic variant PPA (svPPA), nonfluent/agrammatic variant PPA (nfvPPA), and logopenic variant PPA (lvPPA). OBJECTIVE: The aim was to examine the utility of the German version of the Repeat and Point (R&P) Test for subtyping patients with PPA. METHOD: During the R&P Test, the examiner reads out aloud a noun and the participants are asked to repeat the word and subsequently point to the corresponding picture. Data from 204 patients (68 svPPA, 85 nfvPPA, and 51 lvPPA) and 33 healthy controls were analyzed. RESULTS: Controls completed both tasks with >90% accuracy. Patients with svPPA had high scores in repetition (mean=9.2±1.32) but low scores in pointing (mean=6±2.52). In contrast, patients with nfvPPA and lvPPA performed comparably in both tasks with lower scores in repetition (mean=7.4±2.7 for nfvPPA and 8.2±2.34 for lvPPA) but higher scores in pointing (mean=8.9±1.41 for nfvPPA and 8.6±1.62 for lvPPA). The R&P Test had high accuracy discriminating svPPA from nfvPPA (83% accuracy) and lvPPA (79% accuracy). However, there was low accuracy discriminating nfvPPA from lvPPA (<60%). CONCLUSION: The R&P Test helps to differentiate svPPA from 2 nonsemantic variants (nfvPPA and lvPPA). However, additional tests are required for the differentiation of nfvPPA and lvPPA.

Predictive Factors and Amputation Level for Reamputation in Patients With Diabetic Foot: A Retrospective Case-Control Study.

The aim of this study was to assess the rate and level of reamputation in patients who had a previous amputation from diabetic foot. We retrospectively analyzed patients who underwent amputation and reamputation due to diabetic foot in our clinic between 2011 and 2019. Fifty-nine were evaluated as the healed group after the first amputation and 55 were evaluated as the reamputation group. Given 55 patients who needed reamputation: there were 13 finger or ray, 23 transmetatarsal or syme, 18 transtibial, and 1 transfemoral in the first operation. We found the reamputation rate was 65.4% in distal amputations. When serum parameters were examined before the first amputation in each group, there was no statistically significant difference in white blood cells, neutrophils, lymphocytes, platelets, sedimentation, C-reactive protein, total protein, hematocrit, urea, creatinine, and HgA1c values. There was, however, a significant difference between groups in albumin levels. When comorbidities were assessed for smoking, hypertension, duration of diabetes, and number of debridements after the first surgery, a significant difference between groups was found. When peripheral artery disease and chronic renal failure were examined, no significant difference was observed. In our study, it was observed that the rate of reamputation was higher in distal level amputations for diabetic foot patients. Accordingly, albumin values, smoking, hypertension, duration of diabetes, number of debridements after surgery, were seen as risk factors for reamputation patients.

Combined Pathologies in FTLD-TDP Types A and C.

This study investigated the presence of combined pathologies in a large cohort of autopsies that show a primary pathologic diagnosis of phosphorylated 43-kDa TAR DNA-binding protein (FTLD-TDP), the majority of which portrayed clinical phenotypes consistent with primary progressive aphasia or behavioral variant frontotemporal dementia (bvFTD). Thirty-eight cases with FTLD-TDP (30 type-A and 8 type-C) were identified to determine characteristic differences between cases with and without combined pathologies. Findings indicated that combined pathologies co-occur with FTLD-TDP type-A at a high frequency (50%)-greater than when compared to FTLD-TDP type-C cases (12.5%). Those with FTLD-TDP type-A and combined pathologies showed significantly longer lifespans (p < 0.05), and longer disease durations (p < 0.05), than those with only FTLD-TDP type-A. Cases with FTLD-TDP type-A and known genetic mutations tended not to show combined pathology. Those with the GRN mutation and FTLD-TDP type-A showed a significantly younger age of onset (p < 0.05) and younger age at death (p < 0.01) compared to noncarriers. In 1 bvFTD case, we highlight the rare presence of "triple" FTLD-TDP type-A, FTLD-tau, and Alzheimer pathology. The ante- and post-mortem features associated with combined pathologies in FTLD-related disorders are of useful consideration in the stratification of patients to drug trials, and in the development of therapeutic targets for FTLD.

Mid-long term results of manipulation and arthroscopic release in frozen shoulder / Resultados a médio e longo prazo da manipulação e liberação artroscópica de ombro congelado

ABSTRACT Objective: Surgical treatment options should be discussed in cases of frozen shoulder, which is usually treated in a conservative manner. In this study, we evaluated the efficacy of manipulation and arthroscopic release in cases of frozen shoulder which resisted conservative treatment. Methods: A total of 32 patients who underwent manipulation and arthroscopic capsular release in 34 shoulders were included in the study. The average follow-up period was 49.5 months (range: 24-90 months). No reason for onset could be found in 8 (25%) patients, who were classified as primary frozen shoulder; twenty-four (75%) patients were classified as secondary frozen shoulder due to underlying pathologies. The average pre-operative complaint period was 11 months (range: 3-24 months). After arthroscopic examination, manipulation was performed first, followed by arthroscopic capsular release. The range of motion in both shoulders was compared before the procedure and in the last follow-up visit. Constant and Oxford classifications were used to assess functional results, and the results were assessed statistically. Results: Patient values for passive elevation, abduction, adduction-external rotation, abduction-external rotation, and abduction-internal rotation increased in a statistically significant manner between the preoperative assessment and follow-up evaluation (p<0.01). The average change of 47.97±21.03 units observed in the patients' values obtained in the control measurements against the pre-op Constant scores was determined to be statistically significant (p<0.01). According to the Oxford classification, 29 shoulders were sufficient. Conclusion: Successful results can be obtained with arthroscopic release performed after manipulation in patients with frozen shoulder resistant to conservative treatment. Level of Evidence IV, Case Series.

RESUMO Objetivo: As opções de tratamento cirúrgico devem ser discutidas nos casos de ombro congelado que, em geral, são tratadas de modo conservador. Neste estudo, avaliamos a eficácia da manipulação e da liberação artroscópica nos casos de ombro congelado refratário ao tratamento conservador. Métodos: Um total de 32 pacientes submetidos a manipulação e liberação capsular artroscópica em 34 ombros foram incluídos no estudo. O período médio de acompanhamento foi de 49,5 meses (faixa: 24 a 90 meses). Não foi possível determinar o motivo do início da afecção em 8 (25%) pacientes, que foram classificados como ombro congelado primário; 24 (75%) pacientes foram classificados como ombro congelado secundário, devido a patologias subjacentes. O período médio de queixa pré-operatória foi de 11 meses (faixa: 3 a 24 meses). Depois do exame artroscópico, realizou-se manipulação, seguida por liberação capsular artroscópica. A amplitude de movimento em ambos os ombros foi comparada antes do procedimento e na última visita de acompanhamento. As classificações de Constant e Oxford foram usadas para avaliar os resultados funcionais, e os resultados foram avaliados estatisticamente. Resultados: Os valores dos pacientes para elevação, abdução, adução-rotação externa, abdução-rotação externa e abdução-rotação interna aumentaram de modo estatisticamente significante entre a avaliação pré-operatória e a do acompanhamento (p < 0,01). A mudança média de 47,97 ± 21,03 unidades observada nos valores dos pacientes, obtidos nas medidas de controle com relação aos escores de Constant no pré-operatório foi determinada como estatisticamente significante (p < 0,01). De acordo com a classificação de Oxford, 29 ombros foram suficientes. Conclusão: Os resultados bem-sucedidos podem ser atingidos com liberação artroscópica realizada depois da manipulação dos pacientes com ombro congelado, resistentes ao tratamento conservador. Nível de Evidência IV, Série de Casos.

Isolated HAGL lesion after arthroscopic Bankart repair in a professional soccer player.

Post-traumatic anterior shoulder instability commonly occurs following an avulsion of capsulolabral complex from glenoid (Bankart lesion) or rarely after humeral avulsion of the glenohumeral ligaments (HAGL lesion). Arthroscopic Bankart repair offers high success rates of healing. However, trauma following the treatment may cause implant failure or re-avulsion of the treated tissue. We aim to present the diagnosis and treatment of an isolated HAGL lesion in a professional soccer player who had previously undergone arthroscopic Bankart repair.

MID-LONG TERM RESULTS OF MANIPULATION AND ARTHROSCOPIC RELEASE IN FROZEN SHOULDER.

OBJECTIVE: Surgical treatment options should be discussed in cases of frozen shoulder, which is usually treated in a conservative manner. In this study, we evaluated the efficacy of manipulation and arthroscopic release in cases of frozen shoulder which resisted conservative treatment. METHODS: A total of 32 patients who underwent manipulation and arthroscopic capsular release in 34 shoulders were included in the study. The average follow-up period was 49.5 months (range: 24-90 months). No reason for onset could be found in 8 (25%) patients, who were classified as primary frozen shoulder; twenty-four (75%) patients were classified as secondary frozen shoulder due to underlying pathologies. The average pre-operative complaint period was 11 months (range: 3-24 months). After arthroscopic examination, manipulation was performed first, followed by arthroscopic capsular release. The range of motion in both shoulders was compared before the procedure and in the last follow-up visit. Constant and Oxford classifications were used to assess functional results, and the results were assessed statistically. RESULTS: Patient values for passive elevation, abduction, adduction-external rotation, abduction-external rotation, and abduction-internal rotation increased in a statistically significant manner between the preoperative assessment and follow-up evaluation (p<0.01). The average change of 47.97±21.03 units observed in the patients' values obtained in the control measurements against the pre-op Constant scores was determined to be statistically significant (p<0.01). According to the Oxford classification, 29 shoulders were sufficient. CONCLUSION: Successful results can be obtained with arthroscopic release performed after manipulation in patients with frozen shoulder resistant to conservative treatment. Level of Evidence IV, Case Series.

OBJETIVO: As opções de tratamento cirúrgico devem ser discutidas nos casos de ombro congelado que, em geral, são tratadas de modo conservador. Neste estudo, avaliamos a eficácia da manipulação e da liberação artroscópica nos casos de ombro congelado refratário ao tratamento conservador. MÉTODOS: Um total de 32 pacientes submetidos a manipulação e liberação capsular artroscópica em 34 ombros foram incluídos no estudo. O período médio de acompanhamento foi de 49,5 meses (faixa: 24 a 90 meses). Não foi possível determinar o motivo do início da afecção em 8 (25%) pacientes, que foram classificados como ombro congelado primário; 24 (75%) pacientes foram classificados como ombro congelado secundário, devido a patologias subjacentes. O período médio de queixa pré-operatória foi de 11 meses (faixa: 3 a 24 meses). Depois do exame artroscópico, realizou-se manipulação, seguida por liberação capsular artroscópica. A amplitude de movimento em ambos os ombros foi comparada antes do procedimento e na última visita de acompanhamento. As classificações de Constant e Oxford foram usadas para avaliar os resultados funcionais, e os resultados foram avaliados estatisticamente. RESULTADOS: Os valores dos pacientes para elevação, abdução, adução-rotação externa, abdução-rotação externa e abdução-rotação interna aumentaram de modo estatisticamente significante entre a avaliação pré-operatória e a do acompanhamento (p < 0,01). A mudança média de 47,97 ± 21,03 unidades observada nos valores dos pacientes, obtidos nas medidas de controle com relação aos escores de Constant no pré-operatório foi determinada como estatisticamente significante (p < 0,01). De acordo com a classificação de Oxford, 29 ombros foram suficientes. CONCLUSÃO: Os resultados bem-sucedidos podem ser atingidos com liberação artroscópica realizada depois da manipulação dos pacientes com ombro congelado, resistentes ao tratamento conservador. Nível de Evidência IV, Série de Casos.

Am I looking at a cat or a dog? Gaze in the semantic variant of primary progressive aphasia is subject to excessive taxonomic capture.

Object naming impairments or anomias are the most frequent symptom in aphasia, and can be caused by a variety of underlying neurocognitive mechanisms. Anomia in neurodegenerative or primary progressive aphasias (PPA) often appears to be based on taxonomic blurring of word meaning: words such as "dog" and "cat" are still recognized generically as referring to animals, but are no longer conceptually differentiated from each other, leading to coordinate errors in word-object matching. This blurring is the hallmark symptom of the "semantic variant" of PPA, who invariably show focal atrophy in the left anterior temporal lobe. In this study we used eye tracking to characterize information processing online (in real time) as non-aphasic controls, semantic and non-semantic PPA participants completed a word-to-object matching task. All participants (including controls) showed taxonomic capture of gaze, spending more time viewing foils that were from the same category as the target compared to unrelated foils, but capture was more extreme in the semantic PPA group. The semantic group showed heightened capture even on trials where they ultimately pointed to the correct target, demonstrating the superiority of eye movements over traditional testing methods in detecting subtle processing impairments. Heightened capture was primarily driven by a tendency to direct gaze back and forth, repeatedly, between a set of related foils on each trial, a behavior almost never shown by controls or non-semantic participants. This suggests semantic PPA participants were accumulating and weighing evidence for a probabilistic rather than definitive mapping between the noun and several candidate objects. Neurodegeneration in PPA thus appears to distort lexical concepts prior to extinguishing them altogether, causing uncertainty in recognition and word-object matching.

Eye movements as probes of lexico-semantic processing in a patient with primary progressive aphasia.

Eye movement trajectories during a verbally cued object search task were used as probes of lexico-semantic associations in an anomic patient with primary progressive aphasia. Visual search was normal on trials where the target object could be named but became lengthy and inefficient on trials where the object failed to be named. The abnormality was most profound if the noun denoting the object could not be recognized. Even trials where the name of the target object was recognized but not retrieved triggered abnormal eye movements, demonstrating that retrieval failures can have underlying associative components despite intact comprehension of the corresponding noun.

Bilateral intertrochanteric and femoral diaphyseal fractures with unilateral proximal tibial fracture: A case report and review of the literature.

INTRODUCTION: Bilateral intertrochanteric femur fractures are relatively rare injuries. This study aims to present a case of a patient with simultaneous bilateral intertrochanteric femur fractures and femoral diaphyseal fractures and proximal tibial fracture with his twelve years follow-up. PRESENTATION OF CASE: A 44-year-old man presented to emergency department after a motor vehicle accident. Bilateral intertrochanteric femur fractures (OTA classification - 31A.1.2) and bilateral femoral diaphyseal fractures (OTA classification - 32A.2) and nondisplaced right proximal tibial fracture (OTA classification - 41B.1) were determined in radiographs. Following closed reduction, fractures were fixed with intramedullary nails bilaterally. Proximal tibial fracture was fixed with cannulated screws following open reduction. At twelfth year follow-up he was able to do his daily activities with minimal limitation. DISCUSSION: High energy traumas, stress fractures, systemic disorders (osteomalacia, chronic renal failure), steroid treatments, seizures and electric injuries are possible causes for bilateral hip factures. However bilateral femoral diaphyseal fractures are mostly due to high energy traumas. Long-term biphosphonate use may also cause bilateral fractures. Single-stage surgery should be performed in order to avoid secondary damages of surgical interventions. All fractures of our patient were fixed in a single session. This prevented further deterioration of patient's status and made rehabilitation easy. CONCLUSION: Careful evaluation of all systems should be performed in multi-trauma patients to find out concomitant injuries. Single staged surgical treatment may decrease morbidities.

Early mobilization with customized TLSO brace in thoracolumbar burst fractures.

OBJECTIVE: This study aimed to research the effectiveness of customized thoracolumbosacral orthosis treatment for stable burst type thoracolumbar vertebral fractures without neurological deficits. METHODS: The study included 26 patients (14 males, 12 females; mean age: 46.03 years; range: 18 to 64 years) conservatively treated for thoracolumbar (T11-L2) burst type vertebral fractures according to Denis classification between 2002 and 2009. Etiology were a fall from various heights in 12 patients (46.2%), motor vehicle accidents as an occupant in 7 (26.9%) and as a pedestrian in 4 (15.4%), and simple fall in 3 (11.5%). None of the patients had neurologic deficit and no damage was found in the posterior ligamentous complex in MRI evaluations. Denis pain and functional scales were used in the clinical evaluation. Local kyphosis angle, sagittal index and height loss percentage were measured in the radiologic evaluation. Post-fracture and follow-up values were compared. Mean follow-up period was 41.30 (range: 14 to 80) months. RESULTS: Mean pain and functional scores were 1.65 and 1.15 points, respectively, at the final follow-up. Twenty patients returned to their pre-trauma work and activities completely and six patients with small limitations. Mean period for returning to work was 3.64 (range: 2 to 6) months. Local kyphosis angle, sagittal index and height loss percentage values increased significantly at follow-up (p<0.05). CONCLUSION: The conservative treatment of stable thoracolumbar burst fractures is widely accepted. Early mobilization with customized TLSO brace appears to produce effective functional results despite loss of vertebral body height.

Intramedullary osteosynthesis of instable intertrochanteric femur fractures with Profin® nail in elderly patients.

OBJECTIVE: The aim of this study was to retrospectively analyze the radiologic and functional results of patients with instable intertrochanteric femur fractures treated with Profin® nails. METHODS: This study included 32 patients (24 female, 8 male; mean age: 70.7 years; range: 65 to 96 years) who were treated with Profin® nails for instable intertrochanteric fractures. Fractures were caused by a simple fall in 30 patients and pedestrian accident in two. Eleven patients had Type 31-A2 and 21 patients had Type 31-A3 fractures according to the AO/OTA classification. Results were evaluated clinically and radiologically. Mean follow-up period was 17.3 (range: 12 to 23) months. RESULTS: Good or acceptable reduction was achieved in 93.7% of our patients. Mean surgery duration was 28.2 (range: 22 to 75) minutes and mean blood loss was 215 (range: 150 to 320) cc. Complete union was achieved in all patients at a mean of 17.6 (range: 15 to 22) weeks. Postoperative mean collodiaphyseal angle was 125.5 (range: 122 to 130) degrees and there was no significant difference with follow-up values (p>0.05). Twenty-two patients were able to walk with support and 10 without support after surgery. Mean Oxford hip score was 23.70 (range: 14 to 39) points. One year mortality rate was 18.75%. CONCLUSION: Good functional and radiologic results can be achieved using Profin® nails for unstable intertrochanteric femur fractures in elderly patients.

Headaches related to psychoactive substance use.

AIM: To investigate a possible association between headache and psychoactive substance use. METHODS: 1055 psychoactive substance abusers were consecutively admitted. All patients filled out a detailed headache questionnaire and 1015 patients were included. RESULTS: Twenty seven percent of patients reported having headache. Eighteen percent of patients reported having headache attributed to a substance or its withdrawal and 1.4% had unclassified headache. The most commonly used substances were cannabis (80.5%), alcohol (74.6%), methylamphetamine (18.7%), benzodiazepine (10.4%), volatile solvent (5.8%), cocaine (4.4%), heroin (2.1%), opioids (0.5%), and other substances (1.7%). Fifteen patients reported that onset of headache occurred prior to onset of substance use, while 94.5% had headaches occurred after substance abuse. A higher incidence of headache was found in the benzodiazepine, methylamphetamine, cocaine, heroin, volatile solvent abusers. Seventy-eight percent of headache patients have never sought help from a physician despite the severity and frequency of headache. CONCLUSIONS: In our study, the prevalence of headache among all psychoactive substance abusers was 26.9%. Although this is one-group study without any comparison with non-addict population and associational data must be interpreted with caution, the results of this study indicate a possible relationship may exist between headache and substance use since 94.5% of substance users described headaches after the onset of substance use. The younger start and the longer duration of cannabis use caused the higher incidence of headache, but this correlation was not observed in other substance use. Migraine was far more prevalent in the abusers than in previously reported community populations.

Focal status epilepticus induced by hyperbaric oxygen therapy.

INTRODUCTION: generalized tonic clonic (GTC) seizure activity because of central nerve system oxygen toxicity is a rare but recognized effect of HBOT (hyperbaric oxygen therapy). Almost all case reports and database analyses about the relationship between seizure activity and HBOT point out that GTC seizures and status epilepticus are more likely to occur as a result of the treatment and there are only few reports demonstrating partial seizures. CASE REPORT: an 87-year-old male patient was admitted to our clinic because of tonic-clonic contractions on his left arm. He was under HBOT because of a decubitis ulcer. After repeated exposures to hyperbaric oxygen, he had contractions on his left arm. He was diagnosed as focal motor status. There was no evidence of acute ischemia or mass lesion on brain magnetic resonance imaging. IV phenytoin (diphenylhydantoin) 20 mg/kg was given over 30 minutes and continued orally with phenytoin at a dose of 300 mg/d. He had no subsequent seizures. CONCLUSION: GTC seizures or status epilepticus as a result of GTC seizures are more common than focal seizures as neurologic complications of HBOT. Partial seizures as a neurologic complication of HBOT have rarely been reported and to our knowledge, this is the first case which is characterized by focal status epilepticus induced by HBOT.

The results of surgical treatment for posttraumatic heterotopic ossification and ankylosis of the elbow.

OBJECTIVES: Heterotopic ossification which may develop following elbow injuries or elbow surgery may result in complete loss of elbow functions. We evaluated the results of surgical treatment for ankylosis of the elbow due to posttraumatic heterotopic ossification. METHODS: The study included seven patients (6 males, 1 female; mean age 36 years; range 23 to 55 years) who developed heterotopic ossification and ankylosis of the elbow joint following surgical treatment of high-energy fractures in the circumference of the elbow. Two patients had comminuted olecranon fractures and elbow luxation, and five patients had comminuted intra-articular distal humeral fractures. Three patients had open fractures. Involvement was in the right elbow in two patients, and in the left elbow in five patients. One patient was monitored and treated in the intensive care unit for head trauma for 22 days. Initially, six patients were treated with plate osteosynthesis and one patient with tension band wiring. Foci of heterotopic ossification were detected on the radiographs taken after a mean of 24 days (range 20 to 32 days) following surgical treatment of fractures. The patients were followed-up with conventional radiography and scintigraphy for a mean of 11 months (range 7 to 15 months) before surgical treatment, during which functional loss in elbow joint movements deteriorated and ankylosis developed. All the patients had Hastings type IIIC ankylosis and poor Mayo elbow performance scores (mean score 50.7). A posterior incision was used in three patients, and a double-column incision was used in four patients. At surgery, the ulnar nerve and the lateral and medial collateral ligaments were preserved, and a posterolateral capsular release, removal of heterotopic ossification, purging of the olecranon fossa, and resection of the tip of the olecranon were performed. After completion of capsular release, cartilage pathologies were evaluated. Four patients were found to have no definite cartilage damage, whereas in three patients the joint cartilage was seriously damaged. At final controls, the patients were assessed with the Mayo elbow performance score. The mean follow-up period was 23.4 months (range 10 to 36 months). RESULTS: In all cases, the range of motion and stability of the elbow joint were controlled and were found to be complete and stable at the end of the operation. At final controls, the Mayo elbow performance scores were good in three patients, moderate in one patient, and poor in three patients. All the patients with a poor elbow score had severe joint cartilage damage intraoperatively. CONCLUSION: Patients who develop heterotopic ossification and ankylosis of the elbow following trauma or elbow surgery may benefit from removal of heterotopic ossification foci and elbow relaxation procedures provided that there is not severe damage to the articular cartilage.