Arterial blood gas analysis predicts futile recanalization in mechanical thrombectomy-treated acute ischemic stroke patients: a multicenter study.

OBJECTIVE: It is known that providing recanalization alone in large vessel occlusions is not sufficient to provide a good 90-day clinical outcome. It is advocated that neuroprotection should be increased before endovascular treatment and that the penumbra should be protected from reperfusion damage after recanalization. However, the effects of blood gas parameters before and after mechanical thrombectomy on clinical outcomes are not clear. The objective of this study is to assess the effectiveness of serial blood gas measures in accurately predicting futile recanalization at an early stage. PATIENTS AND METHODS: This study is a multicenter inquiry that collected data in a prospective manner and analyzed it retrospectively. Patients with a 2b-3 thrombolysis in cerebral infarction (TICI) score after mechanical thrombectomy for recanalization were consecutively analyzed from July 2022 to March 2023. Arterial blood gas parameters, including pH, oxygen saturation (SaO2), partial carbon dioxide pressure (PaCO2), partial oxygen pressure (PaO2), lactate, and bicarbonate (HCO3), were measured at four time points: before mechanical thrombectomy treatment (preoperative), immediately after recanalization (postoperative 1st), during the 3rd hour (postoperative 3rd), and at the 5th hour (postoperative 5th). The patients were categorized into groups based on their modified Rankin Scale (mRS) scores. RESULTS: The study included 136 patients with an average age of 69.71±11.22. The postoperative 1st-hour SaO2 values were lower in the mRS 3-6 group (p=0.038). The postoperative pH and lactate mean were greater in the mRS 3-6 group than in the 0-2 group (p=0.038 and 0.018, respectively). In logistic regression, a unit rise in lactate increased poor functional outcomes 1,632 times (p=0.024). Early neurological recovery was associated with decreased postoperative 3rd-hour lactate (p=0.014). The mean postoperative PaO2 (average of 1, 2, 3 PaO2) was higher in those with symptomatic cerebral bleeding (p=0.044). CONCLUSIONS: Monitoring lactate and pH levels in AIS patients who have had mechanical recanalization can be utilized to predict mortality and morbidity, especially in the first five hours after the procedure. Graphical Abstract: https://www.europeanreview.org/wp/wp-content/uploads/Graphical-abstract-8.jpg.

The relationship between albumin and its proportion to other markers in predicting mortality in severe COVID-19 patients.

OBJECTIVE: The aim of the present study was to investigate the relationship between albumin, blood urea nitrogen (BUN)/albumin ratio (BAR), D-dimer/albumin ratio (DAR), C-reactive protein (CRP)/albumin ratio (CAR), and neutrophil/albumin ratio (NAR) levels and prognosis in severe COVID-19 cases. PATIENTS AND METHODS: A total of 619 patients diagnosed with severe COVID-19 in the emergency department were retrospectively analyzed. BAR, DAR, CAR, and NAR values were obtained by dividing BUN, neutrophil, CRP, and D-dimer by albumin. All patients were divided into groups [survived and deceased patients, and those who received and did not receive mechanical ventilation (MV) assistance]. These groups were statistically compared with regard to albumin, BAR, DAR, CAR, and NAR. RESULTS: While 350 out of 619 patients survived, 269 patients died. A statistically significant difference was determined between survived and deceased patient groups with regard to BUN, neutrophil, lymphocyte, CRP, D-dimer, albumin, BAR, NAR, DAR, and CAR levels (p<0.001 for all). Also, BAR, NAR, DAR, and CAR were significantly higher in those who received MV support, while albumin was found to be low (p<0.001). According to receiver operating characteristic (ROC) analysis, NAR, BAR, CAR, albumin, and DAR had the highest area under the curve (AUC) values compared to the other parameters (0.825, 0.815, 0.806, 0.772, and 0.770, respectively) (p<0.001 for all). According to logistic regression analysis, BAR, NAR, DAR, and CAR levels were determined as important risk factors for mortality. CONCLUSIONS: Low serum albumin levels can be used for severity as an additional tool in severe COVID-19 patients. Moreover, the NAR, BAR, and CAR levels were found to be more valuable than albumin levels in predicting prognosis in these patients.

A randomized controlled trial examining the impact of low vs. moderate-intensity aerobic training in post-discharge COVID-19 older subjects.

OBJECTIVE: Post-COVID-19 patients complained of pain, fatigue, breathlessness, and reduction in quality of life which required planned intervention. This study aimed to compare the impact of 10 weeks of low vs. moderate-intensity aerobic training on physical fitness, psychological status, and quality of life in post-COVID-19 older subjects. PATIENTS AND METHODS: 72 patients were randomized into 3 equal groups, moderate-intensity exercise (MIG, n = 24), low-intensity exercise (LIG, n = 24), and control group (CG, n = 24). The exercise was done 40 min/4 times per week for 10 weeks. We measured exercise capacity using the six-minute walking test, 1 min sit-to-stand test, post-COVID-19 functional scale (PCFS), and quality of life using the SF-36 questionnaire and HAMILTON Anxiety and Depression Scale (HADS). RESULTS: There was no difference between groups regarding the demographic and most clinical characteristics of the subjects. Compared with CG there were statistically significant improvements in studying groups (MIG and LIG) with (p < 0.05) in most outcomes and the improvement was higher in MIG than in LIG in most outcomes. CONCLUSIONS: 10-week moderate-intensity and low-intensity aerobic training programs are effective with superior effect to moderate-intensity. Moderate-intensity aerobic exercise is more effective and feasible in post-discharge COVID-19 older subjects regarding exercise capacity, quality of life, and psychological status than low-intensity aerobic exercise.

Predictive value of systemic immune-inflammation index for cerebral reperfusion and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment.

OBJECTIVE: The systemic immune inflammation (SII) index has been an excellent prognostic indicator in patients with acute ischemic stroke (AIS). In this study, we assessed the utility of the SII in predicting the prognosis and reperfusion status of patients with AIS who underwent endovascular treatment (EVT). PATIENTS AND METHODS: 123 consecutive AIS patients were enrolled in our study. The receiver-operating characteristics (ROC) curve was used to determine the cut-off value of SII for predicting unsuccessful cerebral reperfusion. Multivariate logistic regression analysis analyzed the association between SII and unsuccessful reperfusion rate after EVT. RESULTS: The median value of SII was significantly higher in patients with unsuccessful reperfusion compared to patients with successful reperfusion [2,029 (1,217-2,771) vs. 1,172 (680-2,145) respectively, p=0.003)]. A ROC curve analysis showed that the best cut-off value of SII for predicting unsuccessful reperfusion status was 1,690, with sensitivity and specificity of 71% and 69%, respectively. The area under the curve (AUC) was 0.673 (95% CI; 0.552-0.793). Multivariate analysis demonstrated that SII ≥ 1,690 value was an independent predictor of unsuccessful cerebral reperfusion and unfavorable clinical outcome after EVT (Hazard ratio - H.R.=3.713, 95% CI: 1.281-10.76, p=0.016, HR=2.28, 95% CI: 1.06-4.88, p=0.035, respectively). CONCLUSIONS: We suggested that SII is a potential indicator to predict the unsuccessful cerebral reperfusion and unfavorable clinical outcome for patients with AIS undergoing EVT.

Comparison of COVID-19 patients who underwent thrombectomy with those in the pre-pandemic period in terms of etiology and prognosis.

OBJECTIVE: We aimed at determining the effectiveness of mechanical thrombectomy (MT) in patients with major vessel occlusion and infected with COVID-19, evaluating its clinical outcome and comparing it with non-COVID patients. PATIENTS AND METHODS: During the pandemic, 729 patients who underwent MT in stroke centers due to Acute Ischemic Stroke (AIS) with large vessel occlusion were evaluated. This study included 40 patients with a confirmed COVID-19 diagnosis by a positive PCR test between March 11, 2020, and December 31, 2020. These patients were compared to 409 patients who underwent MT due to major vessel occlusion between March 11, 2019, and December 31, 2019. RESULTS: Of the patients with AIS who are infected with COVID-19, 62.5% were males, and all patients have a median age of 63.5 ± 14.4 years. The median NIHSS score of the COVID-19 group was significantly higher than that of the non-COVID-19 groups. Dissection was significantly more in the COVID-19 group. The mortality rates at 3 months were higher in the COVID-19 groups compared to non-COVID-19 groups. CONCLUSIONS: This study revealed an increased frequency of dissection in patients with COVID-19. COVID-19-related ischemic strokes are associated with worse functional outcomes and higher mortality rates than non-COVID-19 ischemic strokes.

How childhood trauma and emotions influence essential tremor and its severity in Sakarya Province.

OBJECTIVE: Essential tremor (ET) is among the most common central nervous system disorders. It is characterised by symmetrical and bilateral postural tremor, usually affecting the hands. Alongside such motor symptoms, psychiatric symptoms, such as anxiety and depression, often occur. This study aimed to investigate how anxiety, depression and childhood trauma influence ET patients' tremor frequency and severity. PATIENTS AND METHODS: The participants comprised 85 patients and 70 control volunteers. Participating patients have been admitted to our clinic for hand tremor complaints and diagnosed with ET, according to the Washington Heights Inwood Genetic Study of Essential Tremor (WHIGET) diagnosis criteria, and they returned for follow-up for at least one year after their initial treatment. Patients with thyroid dysfunction, Parkinson's disease, central nervous system pathology, a history of smoking or alcohol use or a history of drug use that may cause tremor were excluded from the study. Patients' demographic data, such as their age and gender, age at disease onset, disease duration, family history and tremor severity were recorded. The Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and Childhood Trauma Questionnaire (CTQ) were applied to all patients. RESULTS: Statistically significant differences were found in BDI score averages and BAI score averages between the patient and control groups (p = 0.002; p = 0.001) and physical abuse, emotional neglect and sexual abuse scores on the CTQ scale (p = 0.001, p = 0.007 and p = 0.001, respectively). CONCLUSIONS: Childhood mental trauma and emotional mood disorders are more common among ET patients. However, these disorders do not appear to affect ET severity.

Should coronary catheter laboratories be used in the treatment of ischemic stroke? Endovascular treatment in acute ischemic stroke performed by interventional cardiologists.

OBJECTIVE: The aim of this study was to investigate the technical success and in-hospital outcomes of endovascular thrombectomy (ET) in acute ischemic stroke (AIS) patients performed by interventional cardiologists. PATIENTS AND METHODS: ET for AIS provides fast, effective and safe recanalization. Insufficient number of catheter laboratories for stroke interventions and experienced interventional neurologists are limiting the widespread application of such a promising treatment method. RESULTS: 123 patients with AIS and eligible for ET were evaluated retrospectively. 65 patients were female (52.8%) and the mean age of the patients was 71.5 ± 11.9 years. Most of the patients had a middle cerebral artery (MCA) occlusion (112 patients, 91%). Successful recanalization (thrombolysis in cerebral infarction grading 2b or higher) was achieved in 109 patients (88.6%). Access site complication was observed only in 3 patients (2.4%). Intracranial bleeding was observed in 17 patients (13.8%) and only 8 of them were symptomatic (6.5%). In-hospital death occurred in 19 patients (15.4%). The initial National Institutes of Health Stroke Scale (NIHSS) was 16.8±3.3 (median 18) which improved significantly to 10.4±7.2 (median 11) at 24 hours (p<0.001). Dramatic neurologic improvement was observed in 60 of 123 patients (48.8%). The modified rankin score of the patients was significantly lower at discharge compared to admission (4.2±0.7 vs. 2.9±2, p<0.001). CONCLUSIONS: ET in AIS can be performed safely with high success rates by trained interventional cardiologists within the stroke team. Until the number of stroke centers is sufficient, endovascular treatment of AIS can be supported by experienced interventional cardiologists.

Specialist physicians battle against the COVID-19 pandemic: the relationship between specialist physicians working conditions and levels of burnout during the COVID-19 pandemic.

OBJECTIVE: This study was planned to determine the burnout levels of physicians during the COVID-19 pandemic, and to contribute to taking the necessary measures by determining the associated factors. MATERIALS AND METHODS: This research was designed via Google Online Form as an online survey with questions of Sociodemographic Data Form, Maslach Burnout Inventory and Beck Anxiety Inventory and was conducted with 40 specialist physicians actively working at the Sakarya University Training and Research Hospital. The same questionnaire was re-applied online after two months, and 24 out of 40 physicians were accessed. The SPSS 25 (IBM, Armonk, NY, USA) program was used for the analysis of the data. RESULTS: According to the Maslach Burnout Inventory applied in the pre-test, it was found that the feeling of personal accomplishment was high, emotional burnout was normal, and depersonalization was low. Anxiety and burnout were found to be positively correlated, and there were no statistically significant differences in the average values of the pre-and post-test Maslach Burnout Inventory and Beck Anxiety Inventory scores. CONCLUSIONS: Detecting possible burnout in physicians working in a pandemic, identifying associated factors and taking required measures can be beneficial both for physicians and society from a biopsychosocial perspective.

Do tumor localization, microsatellite instability and mismatch repair deficiency have an impact on the prognosis of colorectal cancer?

BACKGROUND: Recent reports have shown that left-and right-sided colon cancers display different clinical and biological features. Chromosomal instability, epigenetic alterations, and defects in the deoxyribonucleic acid (DNA) mismatch repair (MMR) system may lead to the development of colorectal cancer (CRC). Besides microsatellite instability (MSI) caused by DNA MMR activity degradation increases the risk for CRC. AIM: We aimed to show the differences between CRCs in different locations, to research the cause of these differences, to present whether there is a relation between MMR and MSI, and to evaluate their effects on prognosis. PATIENTS AND METHODS: 641 CRC cases were divided into three groups: Group 1 (right-sided), Group 2 (left-sided), and Group 3 (rectum). Demographics, cancer stages, location of the tumors, number of the lymph nodes removed, MMR deficiency or proficiency, MSI status, and survival were assessed by retrospective review of the patients. RESULTS: Among 641 patients, 64.9% were males. Group 1, 2, and 3 comprised 31.2%, 45.7%, and 23.1% of all the cases, respectively. There was a significant difference in terms of survival and location only in stage II tumors. Stage II left colon cancer (LCCs) had a statistically significant lower survival rate. There was no significant difference in survival between both MSI and MMR statuses. In addition, cases were also stratified by stages. According to this data, 10.1, 45.7, and 44.2% of the patients had stages I, II, and III disease, respectively. CONCLUSIONS: Although it was not statistically significant, tumors with MMR deficiency (dMMR) and high microsatellite instability (MSI-H) are more common in right-sided colon tumors.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure.

BACKGROUND: Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. AIMS: In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. METHOD: This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. RESULTS: In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. CONCLUSION: LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Endoscopic resection for giant oesophageal fibrovascular polyp.

A fibrovascular polyp is a rare benign pseudotumour of the oesophagus and hypopharynx. Although patients usually present with dysphagia, aspiration related mortality may occur. If the tumour is too large and/or located in the proximal oesophagus, it may protrude from the mouth. The general approach to treatment is complete reconstruction with cervicotomy. We present our experience of a giant oesophageal fibrovascular polyp that was protruding from the mouth and treated with endoscopic resection. A 55-year-old man was admitted to our outpatient clinic complaining of a mass protruding from his mouth when he coughed. Endoscopy and bronchoscopy both revealed a 15-18cm long polypoid mass originating from the proximal oesophagus (at the level of the hypopharynx). Complete resection was performed via endoscopy.

House advancement flap anoplasty for severe post-hemorrhoidectomy anal stenosis.

Anal stenosis (AS), which is a very rare but serious complication, usually develops after hemorrhoidectomy. It may be mild, moderate or severe depending on the grade of stenosis. While mild and moderate types can be monitored with conservative treatment, most of the severe type require advancement flap anoplasty. There are several commonly used flap types such as Y-V, diamond and house-type flaps, but the best results belong to house-type flaps. In this paper, we aimed to present a case of severe post-hemorrhoidectomy AS, in which we performed house advancement flap anoplasty, with its video demonstrating the procedure step by step.

Parathyromatosis: a very rare cause of recurrent primary hyperparathyroidism - case report and review of the literature.

Parathyromatosis is a rare entity and usually appears as a consequence of the seeding on previous parathyroid surgery which was applied for the secondary hyperparathyroidism. A 63-year-old woman presented with a history of subtotal thyroidectomy 20 years ago and parathyroidectomy due to primary hyperparathyroidism (PHPT) four years ago. Imaging methods revealed multiple parathyromatosis foci on subcutaneous tissue of the neck. En-bloc resection was performed and pathological examination confirmed the diagnosis of parathyromatosis. After an uneventful 10 months, biochemical and radiological tests revealed recurrence on bilateral thyroid lodges. En-bloc resection was performed. The patient has remained well for 24 months after the second operation and has been followed-up with normal parathormone and serum calcium values. To the best of our knowledge, this report describes the twenty-first case of parathyromatosis in PHPT setting in the literature. It should be kept in mind that parathyromatosis may recur at different sites in the neck even in patients with PHPT.

Intraoperative nerve monitoring during thyroidectomy: evaluation of signal loss, prognostic value and surgical strategy.

INTRODUCTION: Intraoperative neural monitoring of the recurrent laryngeal nerve has been widely used to avoid nerve injury during thyroidectomy. We discuss the results of the change in surgical strategy after unilateral signal loss surgeries using intermittent intraoperative neural monitoring in a high-volume referral centre. MATERIALS AND METHODS: Details of consecutive patients who underwent thyroidectomy with intermittent intraoperative neural monitoring between January 2014 and December 2017 were prospectively recorded and retrospectively reviewed. Loss of signal was defined as recurrent laryngeal nerve amplitude level lower than 100 µV during surgery. The rate of loss of signal and change in surgical strategy during the operation were evaluated. RESULTS: Loss of signal was detected in 25 (5.4%) of 456 patients for whom intermittent intraoperative neural monitoring was performed. Four patients had anatomic nerve disruption and surgery was completed by an experienced endocrine surgeon making use of intraoperative neural monitoring with continuous vagal stimulation. Staged thyroidectomy was performed on 16 patients with unilateral loss of signal in whom the nerves were intact visually. Postoperative vocal cord paralysis was encountered in 18 of 21 (85.7%) patients with loss of signal, and 16 of 18 (88.8%) were improved during the follow-up period. Patients' voices were subjectively normal to the surgeon postoperatively in 9 of 21 (42.8%) patients who were found to have loss of signal with intact nerves. CONCLUSIONS: Intraoperative neural monitoring can be used safely in thyroid surgery to avoid recurrent laryngeal nerve injury. It enables the surgeon to diagnose recurrent laryngeal nerve injury intraoperatively to estimate the postoperative nerve function and to modify the surgical strategy to avoid bilateral vocal cord paralysis.