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November 2015


Original Article

Assesment of Hand grip Strength in Patients with Pelvic Organ Prolapse

Aliye Yıldırım Güzelant 1, Nicel Taşdemir 2, Ayşe Banu Sarıfakıoglu 1, Remzi Abalı 2, Cem Çelik 2

1 Department of Physical Medicine and Rehabilitation, 2 Department of Obstetrics and Gynecology, Namik Kemal University School of Medicine, Tekirdag, Turkey

DOI: 10.4328/JCAM.2416 Received: 23.03.2014 Accepted: 16.04.2014 Published Online: 16.04.2014

Corresponding Author: Aliye Yildirim Guzelant, Namık Kemal University School of Medicine, Department of Physical Medicine and Rehabilitation, 100. Yıl Mah, Tunca Cad, 59100, Tekirdag, Turkey. T.: +90 2822505181 GSM: +905052583840 F.: +90 2822509950 E-Mail: aliyeguzelant@gmail.com

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Abstract

Aim: Pelvic organ prolapse(POP) is a common condition that is observed in 50% of parous women. Weakness of pelvic floor muscles is an important factor that leads to POP. The hand grip strength is related to total muscle strength and it could be used to evaluate one’s general muscle strength. The Jamar hand dynamometer is a portable dynamometer that uses a strain gauge to measure hand grip strength. We hypothesized that general mus-cle strength would be impaired in patients with POP. Material and Method: Twenty patients with pelvic organ prolapse and twenty-one controls were recruited from the gynecology clinic of Namik Kemal University School of Medicine. The POP-Q classification was used to quantify the clinical severity of the prolapse. Hand grip strength was measured using a JAMAR hydraulic hand dynamometer. Results: The median pelvic organ prolapse score was 3 (1-4) in prolapse group. The mean Jamar scores of both groups were similar for the right hand, the left hand and the dominant hand (p=0.774, p=0.575 and p=0.707, respectively).The mean body fat percentage was 33.9 ± 5.7 % in prolapses group and it was 38.9 ± 7.4% in control group (p=0.021). Discus-sion: We found no difference in terms of general muscle strength between POP group and healthy controls. Our results showed that Jamar scores, which represented general muscle strength of body, did not related to pelvic organ muscle strength.

Keywords: Pelvic Organ Prolapse; Hand Grip Strength; Muscle Strength

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Introduction

Pelvic organ prolapse (POP) is the prolapse of anterior (urethrocele, cystocele) and/or posterior (enterocele, rectocele) vaginal walls with or without apical segment of the vagina (cervix, cuff or uterine) [1]. Women with POP have symptoms such as pelvic heaviness, dragging sensation in the vagina, protrusion of vagina or uterus from the vulva and backache. Bladder and bowel symptoms, and sexual dysfunction are evident. POP is a common condition that is observed in 50% of parous women and 10% of these women undergo surgery for the management of POP or urinary incontinence [2, 3].

Pelvic floor is composed of muscles, bones and ligaments. The muscles of pelvic floor are innervated by peripheral and central nerves [4].Weakness of pelvic floor muscles is an important factor that leads to pelvic organ prolapse. Moreover, grip strength is related to total muscle strength and it could be used to evaluate one’s general muscle strength [5]. The Jamar hand dynamometer is a portable dynamometer that uses a strain gauge to measure hand grip strength. We hypothesized that general muscle strength would be an indicator of pelvic floor muscle strength and we evaluated the association of hand grip strength and POP.

Material and Method

Patients with pelvic organ prolapse and age matched healthy controls were recruited between October 2011 and December 2013 from the gynecology clinic of Namik Kemal University School of Medicine. The study was approved by the local research and ethics committee. Informed consent was obtained from each subject immediately before testing.

All women were postmenopausal and also they were not using hormone replacement therapy. In the pelvic organ prolapse (POP) group the women were patients who were scheduled for surgery or treated with pessary. The women in POP and control groups had not any history of surgery within one-year period and had no orthopedic or musculoskeletal disorders (such as upper extremity functional limitation, inflammatory arthritis, entrapment neuropathies, polyneuropathies, neurological disorders and patients with history of trauma) that would affect results. The age-matched patients were chosen for the control group to avoid disturbance in JAMAR scores by aging. Age, body mass index (BMI), body fat percentage (BFI), POP stage, hand grip strength were recorded for each patient. The POP-Q classification was used to quantify the clinical severity of the prolapse. There are three reference points anteriorly (Aa, Ba, and C) and three posteriorly (Ap, Bp, and D). The points Aa and Ap are 3 cm proximal to the hymenal ring anteriorly and posteriorly, respectively. Points Ba and Bp are defined as the lowest points of the prolapse between Aa anteriorly or Ap posteriorly and the vaginal apex. Anteriorly, the apex is point C (cervix), and posteriorly is point D (pouch of Douglas). The vaginal length, the genital hiatus from the middle of the urethral meatus to the posterior hymenal ring, and the perineal body from the posterior aspect of the genital hiatus to the midanal opening are also noted in POP-Q. Once the measurements are noted, corresponding POP-Q stage is calculated (Between 0 and 4) [1]. Hand grip strength was measured using a JAMAR hydraulic hand dynamometer [Figure 1(a-b)]. Both hands were tested three times and the average of results was used for each hand. The measurement was performed between 9 and 11 am to avoid muscle weakness in the sitting position with the arm held in a comfortable position as previously described by Spijkerman et al. [Figure 2(a-b)] [6].

Statistical analyses were conducted using the Statistical Package for the Social Sciences for Windows 20.0 software (SPSS, Chicago, IL, USA). Descriptive statistics were given as mean, standard deviation, median, min-max, frequency and percentage. The Kolmogorov Smirnov test was used to evaluate whether the continuous variables were normally distributed. For continuous variables the independent samples t-test or Mann Whitney U-test were used as appropriate. The chi-square or Fisher’s exact test was used to compare nominal variables. A probability value < 0.05 was considered the minimum level of statistical significance. A two-sided p-value was considered for all comparisons.

Results

Twenty-one patients with POP and twenty-one controls were recruited for this study. A patient with POP refused to participate to the study and the study were conducted with twenty patients. Patients’ mean ages were similar in both groups (p=0.457). The mean value of BMI was 27.9 ± 4.5 kg/m2 in prolapses group while it was 32.9 ± 8 kg/m2 in control group (p=0. 019). The mean body fat percentage was 33.9 ± 5.7 % in prolapses group and it was 38.9 ± 7.4% in control group (0. 021). The mean Jamar scores of both groups were similar for the right hand, the left hand and the dominant hand (p=0.774, p=0.575 and p=0.707, respectively) (Table 1). The median pelvic organ prolapse score was 3 (1-4) in prolapse group. The mean hand floor distances were similar (p=0.728) (Table 1).

Discussion

Pelvic floor muscles are the structural supports of the pelvic organs and pelvic apertures [7]. The weakness of pelvic floor muscles is one of the major risk factors of POP while the etiology is complex and multifactorial. The impaired general muscle strength would be related to weakness of pelvic floor muscles [8]. We hypothesized that hand grip strength would be an indirect indicator of pelvic floor muscle strength. Thus we compared the hand grip strength of patients with POP with healthy subjects, we could not find any difference of muscle strength between two groups. To the best of our knowledge it is the first study in the literature.

The decrease in estrogen levels in postmenopausal women distorts collagen configuration and decreases the body muscle mass. Thus it was reported that risk of POP increased in postmenopausal women [9]. Another study of Nicolay et. al. [10] showed that estrogen supplementation facilitated peripheral muscle strength. Moreover postmenopausal women who received hormone replacement therapy had lower incidence of POP [11]. In the light of these findings we chose postmenopausal women to avoid confounding effect of hormonal status of women and none of these women were using hormone replacement therapy.

The pelvic floor muscle training, which involves contraction of pelvic floor muscles to improve strength, endurance and timing of contractions, is the main conservative management option to treat or prevent POP. Electrical stimulation and biofeedback could be used during the pelvic floor exercises. It had been shown that the women with POP generated less vaginal closure force during a maximal voluntary contraction than healthy women [12]. All these findings proved that pelvic floor muscle strength is the most important etiologic factor of POP. Hand grip strength reflects physical health and muscle function and has been found to be related to functional limitations [13, 14].Impaired muscle strength, which is detected by hand grip strength, is a good marker of impaired physical performance and related to many diseases such as pulmonary diseases, neurologic diseases and fibromyalgia. Moreover the hand grip strength has a prognostic value for geriatric syndrome including urinary incontinence, losses in activity of daily living, pain, iatrogenic problems [8].Thus we evaluated the hand grip strength in patients’ with POP.

Karabiber et al. [15] designed a study investigating general muscle strength in patients with nocturnal enuresis. They found that general muscle strength, which would be an indicator of striated muscles of pelvis, was lower in patients with nocturnal enuresis. Therefore we hypothesized that general muscle strength would be impaired in patients with POP.

Obesity is one of the risk factors of POP [16]. The obesity has adverse effects on muscle strength and it is thought to be related to deposition of triglyceride in myocytes [17]. All patients in both groups were obese in our study. Thus we eliminated the confounding effect of obesity in our study.

The limitations of our study are limited subject numbers and wide disturbance of patients’ ages. We could not compare the subgroups that were stratified by age due to limited number of subjects.

In conclusion, we found no difference in terms of general muscle strength between POP group and healthy controls. Our results showed that Jamar scores, which represented general muscle strength of body, did not related to pelvic organ muscle strength. Our study could not show the association between general muscle strength of body and pelvic organ muscle strength. The situation may be related to the low number of cases. Further studies including a larger patient cohort will provide more clear results.

Competing interests

The authors declare that they have no competing interests.

References

1. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American journal of obstetrics and gynecology. 1996 ;175(1):10-7.

2. Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstetrics and gynecology. 1991 ;78(6):1011-8.

3. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstetrics and gynecology. 1997 ;89(4):501-6.

4. Cavkaytar S AO. Current Approaches in the Surgical Treatment of Urinary Stress Incontinence. J Clinical Analytical Medicine. 2014;5(5):444-8.

5. Wind AE, Takken T, Helders PJ, Engelbert RH. Is grip strength a predictor for total muscle strength in healthy children, adolescents, and young adults? European journal of pediatrics. 2010 ;169(3):281-7.

6. Spijkerman DC, Snijders CJ, Stijnen T, Lankhorst GJ. Standardization of grip strength measurements. Effects on repeatability and peak force. Scandinavian journal of rehabilitation medicine. 1991;23(4):203-6.

7. DeLancey JO. Anatomy and biomechanics of genital prolapse. Clinical obstetrics and gynecology. 1993 ;36(4):897-909.

8. Seino S, Yabushita N, Kim MJ, et al. Physical performance measures as a useful indicator of multiple geriatric syndromes in women aged 75 years and older. Geriatrics & gerontology international. 2013 ;13(4):901-10.

9. Nicolay CW, Walker AL. Grip strength and endurance: Influences of anthropometric variation, hand dominance, and gender. International Journal of Industrial Ergonomics. 2005 ;35(7):605-18.

10. Nicolay CW, Kenney JL, Lucki NC. Grip strength and endurance throughout the menstrual cycle in eumenorrheic and women using oral contraceptives. International Journal of Industrial Ergonomics. 2008 ;38(2):211-21.

11. Maltais ML, Desroches J, Dionne IJ. Changes in muscle mass and strength after menopause. Journal of musculoskeletal & neuronal interactions. 2009 ;9(4):186-97.

12. DeLancey JO, Morgan DM, Fenner DE, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstetrics and gynecology. 2007 ;109(2 Pt 1):295-302.

13. Ramlagan S, Peltzer K, Phaswana-Mafuya N. Hand grip strength and associated factors in non-institutionalised men and women 50 years and older in South Africa. BMC research notes. 2014;7(1):8.

14. Taekema DG, Ling CH, Kurrle SE, et al. Temporal relationship between handgrip strength and cognitive performance in oldest old people. Age and ageing. 2012 ;41(4):506-12.

15. Karabiber H, Garipardic M, Uzel M, Davutoglu M, Ozer A, Hasturk Z, Guler E. Hand grip and pinch strength in patients with nocturnal enuresis: is there a role of muscle strength in pathogenesis of enuresis? Neurourol Urodyn. 2011; 30(4):525-8.

16. Kawasaki A, Corey EG, Laskey RA, Weidner AC, Siddiqui NY, Wu JM. Obesity as a risk for the recurrence of anterior vaginal wall prolapse after anterior colporrhaphy. The Journal of reproductive medicine. 2013 ;58(5-6):195-9.

17. Altun BU. The effects of obesity on muscle-skeleton systems Turkiye Klinikleri Journal of Internal Medical Sciences. 2005;1(37):48-52.

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Aliye Yildirim Guzelant, Nicel Tasdemir, Ayse Banu Sarifakioglu, Remzi Abali, Cem Celik. Assesment of Hand grip Strength in Patients with Pelvic Organ Prolapse. J Clin Anal Med. 2015;6(6):771-774

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Pain, Depression and Quality of Life in Patients with Chronic Cervical Miyofascial Pain Syndrome

Ümit Dündar 1, Ahmet Ali Güven 2, Alper Selim Kocaoğlu 2, Hilal Kale 2, Süleyman Kartal 2

1 Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, 2 Öğrenci,Afyon Kocatepe Üniversitesi Tıp Fakültesi, Afyonkarahisar, Türkiye

DOI: 10.4328/JCAM.2453 Received: 01.04.2014 Accepted: 12.04.2014 Published Online: 16.04.2014

Corresponding Author: Ümit Dündar, Afyon Kocatepe Üniversitesi Hastanesi Fiziksel Tıp ve Rehabilitasyon AD. Afyonkarahisar, Turkey. GSM: +905337494526 F.: +90 2722463322 E-Mail: umitftr@yahoo.com

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Aim: The aim of this study was to investigate the levels of depression, pain and disability in patients with chronic cervical miyofascial pain syndrome (MPS) and to determine their association with quality of life. Material and Method: Forty patients with Cervical MPS and 40 age and sex-matched healthy controls enrolled in this study. The social and demographic charac-teristics of the patients and controls were examined. All patients and con-trols were evaluated with respect to pain (at night, rest and movement) and assessed by visual analog scale (VAS). Neck disability index (NDI) was used to calculate functional disability. Quality of life was evaluated with the the Short Form 36 Health Survey (SF-36). Also all of the patients and controls underwent Beck depression inventory (BDI). Results: There was no statistical difference between the patients and control cases according to demographi-cal data. The SF-36 scores of the study patients were lower than controls. NDI, BDI and VAS scores were higher in the patients with chronic cervical MPS compared to controls. BDI scores of the patients with chronic cervi-cal MPS were negatively and closely associated with subparameters of the SF-36 (physical function (r:-0,599, p<0.001), role limitations due to physical functioning (r:-0,558, p<0.001), bodily pain (r:-0.540, p<0.001), general health (r:- 0,708 p<0.001), vitality (r:-0,692, p<0.001), social functioning (r:-0,559, p<0.001), role limitations due to emotional problems (r:-0,537, p<0.001) and mental health (r: -0,787, p<0.001). Discussion: BDI scores are higher in pa-tients with chronic cervical MPS than healthy controls and negatively affect their quality of life. Psychiatric evaluation of the patients with chronic cervi-cal MPS may improve their quality of life and treatments outcome.

Keywords: Chronic Cervical Miyofascial Pain Syndrome; Depression; Quality Of Life

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Giriş

Miyofasiyal ağrı sendromu (MAS), kas ve/veya fasiyalarda tetik nokta ve gergin bantların varlığı ve bu noktaların uyarılması ile yansıyan ağrı, duyusal değişiklikler ve lokal seğirme cevabının gelişmesi ile karakterize bir yumuşak doku romatizması veya bölgesel ağrı sendromudur [1].

Çoğu vakada trapezius kası tutulduğundan boyun ve üst sırt ağrısı MAS’da en sık görülen yakınmadır. Bu sendromun prevalansı son yıllarda dramatik bir artış göstermiştir ve kas iskelet ağrısı nedenleri arasında ön sıralarda yer almaktadır. MAS tedavisinde tetik noktaların inaktivasyonu ve gergin kas bantlarının gevşetilmesi amaçlanır. Hedef, kas gerginliğini yok ederek normal kas uzunluğu, işlev ve gücüne ulaşmak ve hastaların çektiği kronik ağrıyı hafifletmektir [2].

Ağrı, insanın en önemli duyumlarından birisi olup günlük klinik uygulamadaki en yaygın yakınmalardan birini oluşturur. Ağrı fiziksel, davranışsal, emosyonel ve kognitif boyutları olan kompleks bir etkileşim olarak kabul edilmektedir [3]. Kronik ağrı, uykusuzluk, bunaltı ve depresyonla birlikte bulunabilmektedir ve komorbid ya da ikincil olarak gelişmiş bir etkinlik azalmasına yol açarak tıbbi, sosyal ve ekonomik bir sorun olarak ortaya çıkabilmektedir [4]. Kronik ağrısı bulunan hastalarda yüksek oranda depresyon görüldüğü bildirilmektedir [5].

Boyun ağrısının uzun süre devam etmesi hastaların yaşam kalitesinde bozulmalara neden olarak hastalarda üzüntü, çaresizlik duygularının yerleşmesine neden olabilir. Kronik ağrısı olan kişililerin önemli bir bölümünde ek tanı olarak psikiyatrik belirtiler ya da bozukluklar mevcuttur. Psikolojik etkenler fiziksel bozukluklara yol açabildiği gibi, fiziksel bozuklukların da hastaların psikolojisini olumsuz etkilediği kabul edilmektedir. Kronik ağrı sendromlarında depresyon sık görülmekteyken, birincil psikiyatrik bir bozukluk da sıklıkla ağrı nedeni olmaktadır [6].

Fiziksel ağrı ile psikiyatrik bozuklukların birlikteliğindeki neden-sonuç ilişkisi genellikle belirlenememektedir. Biz bu çalışmada, genel toplumda sık karşılaşılan bir sağlık problemi olan servikal MAS hastalarındaki ağrı, disabilite, depresyon düzeyini ve bunların yaşam kalitesi üzerine etkilerini araştırmayı amaçladık.

Gereç ve Yöntem

Çalışmaya yaşları 20-60 arasında değişen 40 (31 kadın/9 erkek) kronik servikal MAS tanılı hasta ve yaş ve cinsiyet açısından benzer 40 (29 kadın/11 erkek) sağlıklı gönüllü (kontrol) dahil edildi. Bu bir olgu kontrol çalışmasıdır. Kronik servikal MAS hastaları için çalışmaya alınma kriteri üç aydan uzun süren kronik servikal MAS hastalık tanısının bulunması idi. Servikal MAS tanısı Simons tarafından önerilen aşağıdaki kriterlere göre koyuldu [7];

Majör kriterler:

1. Boyunda bölgesel ağrı yakınması

2. Miyofasiyal tetik noktanın beklenen yansıyan ağrı dağılımında ağrı yakınması veya değişmiş duyu

3. Palpasyonda gergin bant varlığı

4. Gergin bant boyunca bir noktada şiddetli nokta hassasiyeti

5. Ölçülebilen kısıtlanmış hareket açıklığı

Minör kriterler:

1. Hassas noktaya basınç uygulayarak klinik ağrı yakınmasının veya değişmiş duyunun yeniden oluşturulması

2. Gergin banttaki hassas noktaya çapraz palpasyonla veya iğne sokulması ile lokal seğirme cevabının ortaya çıkması

3. Kası germekle veya hassas noktaya enjeksiyonla ağrının alevlenmesi

Servikal MAS tanısı 5 majör kriter ve en az bir minör kriter varlığında konuldu. Dışlama kriterleri ise; hamilelik, eski spinal cerrahi, vertebranın enflamatuvar, enfeksiyöz veya malign hastalıkları, psikiyatrik tanı ve antidepresan ilaç kullanımı veya öyküsünün bulunması idi. Kontrol grubunu oluşturan sağlıklı gönüllülerin hiçbirisi antidepresan ilaç kullanmıyordu ve psikiyatrik bir tanı almamışlardı.

Hastaların ve kontrol grubunun sosyo-demografik özellikleri sorgulandı. Gece ağrısı, istirahat ağrısı ve hareket ağrısı 10 cm uzunluğundaki görsel anolog skala (GAS) ile değerlendirildi (0: ağrı yok iken 10: en şiddetli ağrı). Fonksiyonel disabiliteyi değerlendirmek için boyun disabilite indeksi (BDİ) kullanıldı. Yaşam kalitesi ise kısa form-36 (SF-36) ile ölçüldü. Hastaların ve kontrol grubunun emosyonel durumları Beck depresyon ölçeği (BDÖ) ile değerlendirildi.

BDİ 10 parçadan oluşur ve her bir parça 0-5 arasında skorlanır. Maksimum skor 50 dir. Elde edilen sonuç 2 ile çarpılarak yüzde skoru elde edilebilir. Bizde bu çalışmada elde edilen skoru 2 ile çarptık [8].

Hastalarda yaşam kalitesi SF-36 ile değerlendirildi. Ölçek 36 maddeden oluşmaktadır ve bunlar 8 boyutun ölçümünü sağlamaktadır: Fiziksel işlevler, sosyal işlevler, fiziksel problemlere bağlı olarak rollerde engellenme, bedensel acı, ruhsal sağlık, duygusal sorunlara bağlı olarak rollerde engellenme, yaşam enerjisi, genel sağlık algısı. Alt ölçekler sağlığı 0 ile 100 arasında değerlendirmektedir ve 0 kötü sağlık durumunu gösterirken, 100 iyi sağlık durumuna işaret etmektedir [9].

Hastaların ve kontrol grubunun depresyon eğilim düzeylerini belirlemek amacı ile BDÖ kullanıldı. Her soruya 0-3 arasında puan verilerek toplam Beck skoru (0-63) elde edildi. BDÖ, depresyon tanısı koymak için değil, kişinin depresyon belirtilerinin derecesini, objektif olarak kendisinin değerlendirmesi için kullanılır. Depresyon derecesi için eşik değer olarak 17 kabul edilmektedir [10].

Gönüllü olur formu çalışma öncesinde bütün hastalardan alınmıştır.

İstatistiksel Analiz; P<0,05 anlamlı kabul edildi. Kolmogorov-Smirnov testi ile verilerin normal dağılım gösterdiği bulundu. Olgu ve kontrol grubunun verilerinin ortalama değerleri Student’ın t testi kullanılarak karşılaştırıldı. Kategorik değişkenlerin karşılaştırılması için Ki kare testi kullanıldı. Olgu grubunda veriler arasındaki korelasyonlar Pearson korelasyon katsayısı testi ile belirlendi. Bütün analizler Windows için SPSS 13.0 programı kullanılarak gerçekleştirildi.

Sonuçlar

Servikal MAS tanılı hastaların ve kontrol grubunun demografik özellikleri Tablo 1’de verilmiştir. Cinsiyet dağılımı, vücut kütle indeksi (VKİ), medeni durumları ve eğitim durumları açısından gruplar arasında anlamlı fark saptanmadı. Servikal MAS tanılı hastaların GAS ile hareket ağrısı, gece ağrısı ve istirahat ağrısı skorları, kontrol grubuna oranla anlamlı ölçüde yüksek bulundu (p<0,001). Servikal MAS tanılı hastaların BDÖ skorları kontrol grubuna oranla yüksek bulundu (p<0,001). Hastaların BDÖ ortalama değeri 19,3±11,1, kontrol grubunun ise 9,8±9,3 olarak bulundu (Tablo 2). Servikal MAS tanılı hastaların 24’inde (% 60) BDÖ skoru 17 ve üzerindeydi. Kontrol grubunda ise yalnızca 7(% 17,5) olguda BDÖ skoru 17 ve üzerinde tespit edildi. Servikal MAS tanılı hastaların BDİ skorları kontrol grubuna oranla yüksek bulundu (p<0,001). Ayrıca Servikal MAS tanılı hastaların SF-36’nın tüm alt grup skorları kontrol grubuna göre anlamlı olarak daha düşüktü (Tablo 2).

Servikal MAS tanılı hastaların SF-36 skorlarının bazı klinik veriler ile korelasyonlarına bakıldığında; hastaların BDÖ skorları ile SF-36’nın ruhsal sağlık alt grubunda çok iyi derecede negatif korelasyon (r=-0,787, p<0.001); fiziksel işlevler (r=-0,599, p<0,001), fiziksel problemlere bağlı olarak rollerde engellenme (r=-0,558, p<0,001), bedensel acı (r=-0,540, p<0,001), genel sağlık algısı (r=-0,708, p<0,001), yaşam enerjisi (r=-0,692, p<0,001), sosyal işlevler (r=-0,559, p<0,001) ve duygusal sorunlara bağlı olarak rollerde engellenme (r=-0,537, p<0,001) alt gruplarında ise iyi derecede negatif korelasyon saptandı (Tablo 3). Ayrıca GAS gece ağrısı skorlarının SF-36’nın fiziksel işlevler (r=-0,740, p<0,001), fiziksel problemlere bağlı olarak rollerde engellenme (r=-0,609, p<0,001), bedensel acı (r=-0,596, p<0,001), genel sağlık algısı (r=-0,528, p<0,001), duygusal sorunlara bağlı olarak rollerde engellenme (r=-0,501, p<0,001) ve ruhsal sağlık (r=-0,529, p<0,001) alt gruplarında iyi derecede negatif korelasyon; yaşam enerjisi (r=-0,381, p<0,001) ve sosyal işlevler (r=-0,432, p<0,001) alt gruplarında ise orta dercede negatif korelasyon saptandı. İstirahat ve hareket ağrısı GAS skorları sırasıyla SF-36’nın alt gruplarından fiziksel işlevler (r=-0,690, p<0,001 ve r=-0,701, p<0,001), fiziksel problemlere bağlı olarak rollerde engellenme (r=-0,577, p<0,001 ve r=-0,592, p<0,001) ve bedensel acı (r=-0,538, p<0,001 ve r=-0,504, p<0,001) ile iyi derecede negatif korelasyona ve SF 36’nın diğer alt gruplarıyla ile orta derecede negatif korelasyona sahipti (Tablo 3). Hastaların BDİ skorları ise, SF-36’nın fiziksel işlevler (r=-0,801, p<0,001) alt grubunda çok iyi derecede negatif korelasyon; duygusal sorunlara bağlı olarak rollerde engellenme (r=-0,460, p<0,001) alt grubunda orta derecede negatif korelasyon ve SF-36’nın diğer alt gruplarıyla ise iyi derecede negatif korelasyon gösterdi (Tablo 3).

Tartışma

Hastaların bilişsel ve kültürel özellikleri, değerlen¬diricinin deneyimleri, ağrının farklı hastalıklarda farklı nitelikte ve nicelikte olabilmesi, ağrı tanı¬mının yapılmasını güçleştirmektedir [11]. Uluslararası Ağrı Çalışmaları Birliği’ne göre ağrı; “mevcut ya da potansiyel doku hasarı ile ilişkili olarak tarif edilen hoş olmayan duyusal ve duygusal bir deneyimdir” [12]. Kronik ağrı ise 3-6 aydan daha uzun süren ve uzun süreli tedavi gerektiren, öznel ve çok boyutlu yaşan¬tısı olan, duyusal, duygusal, davranışsal ve bilişsel bileşenleri içeren ağrı olarak tanımlanmaktadır [13].

Kronik ağrı stres yaratan bir durumdur, sıklıkla kişisel yetenekleri ve çevresel kaynakları etkileyerek kişide kötü psikolojik dengeye, yaşam kalitesinde azalmaya, disabilitede artmaya ve kişiler arası ilişkilerde zorluklara neden olur [14]. Boyun ağrısı genel popülasyonun %45-%54’ünde görülür [15]. Bir derlemede 1 yıllık boyun ağrısı prevalansının 16.7% ila 75.1% arasında görüldüğü (ortalama %37,2) ve Amerika Birleşik Devletleri’nde işçilerin hastalık nedeniyle çalışamaması nedeniyle oluşan iş gücü kaybının bel ağrısından sonra gelen en sık ikinci nedeni olduğudur [16]. Servikal MAS boyun ağrısının sık görülen nedenlerinden biridir. Hastalığının yeterince tedavi edilememesi hastanın kronikleşmesine yol açmakta kişide ek psikiyatrik problemlerin oluşmasına neden olmaktadır. Kronik servikal MAS’ın ağrı, disabilite gibi negatif sonuçlarından ziyade son yıllarda psikolojik etkileri ön sıralara taşınmaya başlamıştır. Bizim bu çalışmada temel amacımız kronik servikal MAS tanılı hastalarda bir psikiyatrik bozukluk olan depresyon eğilim düzeyini araştırmak ve ayrıca depresyon düzeyinin hastaların yaşam kalitesi, ağrı ve disabilite ile olan ilişkisini değerlendirmekti. Çalışma sonuçlarına baktığımızda, kronik servikal MAS’lı hastalarda depresyon düzeyinin sağlıklı kontrollere göre yüksek olduğunu ve yaşam kalitesinin azaldığını ve bu sonuçların kronik servikal MAS tanılı hastaların ağrı ve disabilite skorları ile yakından ilişkili olduğunu gördük.

Kronik ağrısı bulunan hastalarda en sık görülen psikiyatrik durumun depresyon olduğu genel popülasyonda depresyon sıklığı % 5-8 iken kronik ağrılı hastalarda % 30-54 arasında değiştiği bildirilmektedir [17]. Bir başka çalışmada, kronik ağrının depresyon ve anksiyete ile sıklıkla bir arada görüldüğü, hastanın benlik saygısında düşmeye yol açtığı bildirilmiştir [18]. Yazıcı ve arkadaşlarının [19] yaptığı bir çalışmada ise kronik bel, boyun ve diz ağrısı olan hastalarda anksiyete ve depresyon düzeyinin yüksek olduğu ve yaşam kalitesini olumsuz etkilediği bulunmuştur. Yine literatürde boyun veya bel ağrısı ile depresyon arasındaki ilişkiyi gösteren birçok çalışma vardır [20-21]. Bizim çalışmamızda da sağlıklı bireylerle karşılaştırıldığında, kronik servikal MAS tanılı hastalarda depresyon görülme oranının daha fazla olduğu, tespit edildi.

Kronik servikal MAS hastalarda, anksiyete ve depresyonun sonra mı ortaya çıktığı ya da komorbid bir durum mu olduğu açık değildir. Anksiyete ve depresyon bu tür boyun ağrılarının sebebi değil sonucu olabileceği gibi depresyon, anksiyete ve servikal MAS ağrıları ortak bir biyolojik temele sahip olabilir. Psikolojik stresin, supraspinal desendan ağrı-inhibitör aktivitesinin azalması ve nosiseptif uyarımlara supraspinal aşırı duyarlılık gibi santral faktörler aracılığı ile sefalik ve servikal kaslarda istemsiz kasılmalara neden olduğu düşünülmektedir [22].

Kronik fiziksel özürlü bireylerde disabilite, günlük yaşam aktivitelerinde bağımlılık ve kronik ağrı nedeniyle aktivite kısıtlılığı ve sosyal izolasyon ve depresyon meydana gelmekte, bu da yaşam memnuniyeti ve yaşam kalitesinde düşüşe neden olmaktadır [23]. Aynı şekilde kronik servikal MAS hastalarındaki boyun disabilitesi, ağrı birlikte olan veya sonradan gelişen, anksiyete ve depresyon, kişinin iş yapabilme yeteneğini, günlük yaşam aktivitelerini ve fiziksel performansını olumsuz yönde etkileyerek yaşam memnuniyetini düşürmektedir. Bizim çalışmamızda kronik servikal MAS tanılı hastalarda disabilite, ağrı ve depresyon ile yaşam kalitesi arasında negatif yönlü kuvvetli bir ilişki bulundu. Sağlıklı bireylerle karşılaştırıldığında, ağrı, disabilite, depresyon ve yaşam kalitesi açısından her iki grup arasında da anlamlı bir farklılık olduğu tespit edildi.

Korelasyon analizi kronik servikal MAS tanılı hastaların BDÖ skorlarının SF-36’nın tüm alt parametreleri ile çok yakından ilişkili (negatif korelasyon) olduğunu gösterdi. Literatürü taradığımızda depresyonun yaşam kalitesini olumsuz etkilediğini gösteren yayınlar mevcuttur [24]. Çalışmaya dahil ettiğimiz kronik servikal MAS tanılı hastaların ağrı skorlarının (GAS) SF-36’nın daha çok fiziksel alt grupları ile yakından ilişkili bulunurken, BDÖ skorlarının ise hem fiziksel hem de sosyal alt grupları ile çok yakından ilişkili bulunması servikal MAS tanılı hastalardaki depresyon düzeyinin yaşam kalitesini bozan en önemli nedenlerden biri olabileceği fikrini desteklemektedir.

Bütün bu sonuçları birlikte değerlendirecek olursak kronik servikal MAS tanılı hastalarda, kişilerin hissettiği ağrı ve disabilitenin kişinin hem fiziksel aktivitesini hem de sosyal yaşamını kısıtlayarak yaşam kalitesini bozması, kişide depresif bulgular geliştirebilecek bir ortam gelişmesine neden olabileceği sonucuna varabiliriz. Bu hipotezi Rush ve arkadaşlarının [25] yaptığı bir çalışma desteklemektedir. Bu çalışmada fiziksel açıdan aktif olan kronik bel ağrılı hastalarda depresyon riskinin düşük olduğunu bildirmişlerdir.

Çalışmamızın en önemli kısıtlılıkları çalışmaya dahil edilen vakaların ve kontrollerin sayılarının azlığı ve ayrıca hastaların ve kontrollerin yaşam koşullarının sorgulanmamış olmasıydı. Hastaların ve kontrollerin yaşam koşullarındaki farklılıklar hastaların depresyon skorlarını etkileyebilir.

Sonuç olarak kronik servikal MAS tanılı hastaların hem ağrı skorlarının hem de fiziksel aktivitelerinin, yaşam kalitelerinin ve BDÖ skorlarının kontrollere göre anlamlı olarak daha kötü olduğunu tespit ettik. Bu, bize kronik servikal MAS tanısı konulan hastalarda psikiyatrik değerlendirme yapılmasının faydalı olacağını göstermiştir. Kronik servikal MAS tanılı hastaların BDÖ skorlarının yüksek olması yaşam kalitelerini her alanda belirgin ölçüde etkilemektedir. Özellikle medikal ve fizik tedavinin yetersiz kaldığı, BDÖ skorları yüksek ve yaşam kalitesi skorları düşük olan kronik servikal MAS tanılı hastaların tedavisine davranışsal tedavi ve psikolojik desteğin sağlanmasının hastalardaki başarı sonuçlarını artıracağını düşünmekteyiz.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

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How to Cite

Umit Dundar, Ahmet Ali Guven, Alper Selim Kocaoglu, Hilal Kale, Suleyman Kartal. Pain, Depression and Quality of Life in Patients with Chronic Cervical Miyofascial Pain Syndrome. J Clin Anal Med. 2015;6(6):766-770

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The Role of Lifestyle Modifications in the Management of Migraine Associated Vertigo

Omer Saglam 1, Ugur Karapinar 2, Engin Dursun 1, Bilal Cetin 3, Nergis Coskun 4, Aytug Altundag 5

1 Kasimpasa Military Hospital, Department of Otorhinolaryngology, Istanbul, 2 Agri Military Hospital, Department of Otorhinolaryngology, Agri, 3 Gumussuyu Military Hospital, Department of Otorhinolaryngology, Istanbul, 4 TCSB Ankara Pediatric & Pediatric Hematology Oncology Training and Research Hospital, Department of Otorhinolaryngology, Ankara, 5 Istanbul Surgery Hospital, Department of Otorhinolaryngology, Istanbul, Turkey

DOI: 10.4328/JCAM.2433 Received: 25.03.2014 Accepted: 12.04.2014 Published Online: 16.04.2014

Corresponding Author: Omer Saglam, Kasimpasa Military Hospital, Department of Otorhinolaryngology. Beyoglu, Istanbul, 34404, Turkey. T.: +90 2122387900 GSM:+905445275123 F.: +90 2122387902 E-Mail: drsaglam@yahoo.com

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Abstract

Aim: To determine potential factors that may trigger vertigo attacks and evaluate the efficacy of lifestyle changes. Material and Method: We ana-lyzed medical records of 23 patients with migraine associated vertigo ret-rospectively. In the management of vertigo, lifestyle modifications, including limitation of the possible triggering factors such as diet, sleep problems, stress, physical activity, and other factors associated with migraine were determined for therapy. Result: Response to therapy was defined as greater than 50 % reduction in symptom recurrence and severity rate. Overall, 69,6 % of patients experienced resolution or dramatic reduction of frequency and severity in symptoms of their vertigo attacks. Discussion: With the high rate reduction of the vertigofrequency and severity, life-style modifications is ef-fective therapy for the common problem of migraine associated vertigo.

Keywords: Vertigo; Migraine; Triggering Factors; Therapy

Full Text

Introduction

Migraine-associated vertigo (MAV), also known as vestibular migraine or migrainous vertigo, is a common cause of repeated episodes of vertigo in adult patients [1]. The duration of attacks varies from days to months and usually lasting minutes to hours. Unlike classic migraine, MAV mostly occurs independently of headaches. Vertigo can sometimes be the only symptom of migraine without headache. Triggers to migraine have been identified and these include routine physical activities, stress, anxiety, hypoglycemia, fluctuating estrogen levels, irregular sleep, certain foods, and smoking. Like migraine headaches, there are some similar triggers include stress, sleep deprivation, and hormonal changes in MAV. Non-pharmacological treatments such as dietary changes, regular sufficient sleep, reduction of stress, comfortable exercise habit and avoidance of other triggers are recommended as they are for migraine [2-3]. Most drugs are also used for the prevention of MAV [1].

In this study, we aimed to determine the potential factors that might trigger vertigo attacks and evaluate the efficacy of lifestyle changes to prevent vertigo attack including dietary changes regular sleep, stress reduction, regular exercise and physical activity on patients that diagnosed with MAV.

Material and Method

Twenty-three patients affected by MAV were selected from vertiginous patients referred to our clinic from August 2010 to September 2012.

The criteria for inclusion in the study are as follows: [1] diagnosis of MAV based on the adopted criteria used by Murofushi et al. [4] which was processed on the basis of Neuhauser’s [5] and Brantberg’s criteria [6]. This included presence of moderate to severe, recurrent, or episodic vestibular symptoms; migraine headache according to the International Headaches Society (IHS) criteria, synchronization of vertigo attack with migraine (at least one of migranious headache, photophobia, phonophobia, visual or other auras occurring during at least two vertiginous attack), absence of associated unilateral hearing loss, or other disease causing vertiginous attack [2] information on pathophysiology [3] differential diagnosis of peripheral vestibular disorder.

All patients were asked for possible MAV triggers. Food, stress, irregular meals, sleep pattern, and medications that may trigger MAV were evaluated. Recommendations were individualized according to symptoms and triggered factors. Medical management included dietary changes, sufficient sleep, regular physical activity and exercise, minimizing major-certain stress factors. As a common food triggers cheese, foods containing preservative (MSG) , processed meats, fresh baked yeast goods, pickles, dried fruits, alcohol, artificial sweeteners, chocolate, nuts, beverages were defined. The efficacy of the modifications was evaluated by questionnaire divided into three groups (no recurrence, reduction in symptoms duration and severity, no improvement). Frequency and severity of attacks were also determined.

Results

There were 23 patients (16 women, 7 men) with an average age of 36.5 years (range,24-63 yr). Mean follow-up time was 16 weeks, with a range of 8 to 17 weeks. Most common potential factors that may have triggered vertigo attacks was consuming cheese or its products (Table 1).

5 patients (21.7%, 4 women, 1 men) reported complete resolution of symptoms, 11 (47.8%, 7 women, 4 men) reduction of frequency and severity in symptoms and 7 (30.4% 5 women, 2 men) no improvement. Response to therapy was defined as greater than 50 % reduction in symptom recurrence and severity rate. Overall, 69,6 % of patients experienced resolution or dramatic reduction of frequency and severity in symptoms of their vertigo attacks.

Discussion

MAV is a term used to describe episodic vertigo in patients with history of migraine or with other clinical features of migraine. Migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo [2]. Migraine (14%) and vertigo (10%) are common disorders, affecting the general population. 3.2% of the population have both migraine and vertigo (MAV) [3].

The pathophysiology of MAV is not fully understood but both central and peripheral defects have been observed. The links between the vestibular nuclei, the trigeminal system, and thalamocortical processing centers provide the basis for the development of a pathophysiological model of MAV [7].

The headaches and vestibular symptoms of MAV may not be temporally associated [8]. Migraine itself can affect vestibular pathways even if patients do not complain of vestibular symptoms.Vestibular examination alone does not provide enough information for a diagnosis of migrainous vertigo. A careful clinical history is fundamental for assessing the profile of patients with migrainous vertigo [9]. MAV presents with attacks of spontaneous or positional vertigo lasting minutes to days. Headaches are often absent during acute attacks, but other migrainous features such as photophobia or auras, may be present [3]. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms [8].

There are many conditions that are thought to trigger and increase the risk of having a migraine attack. A certain trigger will not induce a migraine in every person. Also in a single migraine sufferer, a trigger may not cause a migraine every time [2,8]. Dietary habits can also play a role. Fasting, dehydration, or skipping meals may also cause vertigo. Some of the most common foods, beverages, and additives that may be associated with migraine. Foods high in tyramine (aged or processed cheese, processed meats, certain beans, onions, olives, pickles, avocados, raisins, nuts) caffeine-containing foods (chocolate, cocoa, coffee, tea, coke etc.) cultured dairy products (sour cream, buttermilk, yogurt), fresh fruits (citrus fruits, papaya, red plums, raspberries, kiwi, pineapple) fresh baked yeast goods (donuts, muffins, cakes, breads, rolls, pizza), dried fruits (figs, raisins, dates), artificial sweetener (aspartame) alcoholic beverages (red wine, beer, and sherry) and foods contains preservatives like MSG may trigger symptoms in MAV [10-12].

Sleep routine is very important. Changes in sleep patterns may cause vertigo like napping, oversleeping, and too little sleep. Having poor sleep routine may trigger migrainous vertigo or cause migraines to become more frequent. Although getting enough sleep is important for people with migraines, having a sleep routine is even more critical. Too little sleep, too much sleep at one time, irregular afternoon naps or any disruption in the regular sleep pattern may trigger vertigo [13,14]. We recommended our patients with MAV to go to bed at the same time and wake up at the same time every day.

The therapeutic effects of exercise like moderate aerobic exercise are well documented and still an option for the prophylactic treatment of MAV. Regular physical activity may improve overall health and also reduce stress. Exercise in some cases, is noted as a trigger for migraine. Exercising suddenly with no prior planning (increased oxygen demand), not eaten properly before exercising (decreased blood glucose levels), not taken sufficient fluids during exercise (dehydration), exercising in heat, over-exercising and pushing themselves too hard may may have the opposite effect and bring on an attack. We suggested mild regular exercise to our patients with MAV like jogging, swimming, cycling, and walking that our patients may enjoy and set as a regular routine. This offered the most benefits to those with migraine. Drinking fluids before, during and after exercise, eating at least an hour and a half before exercising, warming up before and after exercise, wearing the correct clothing, and choosing a comfortable exercise program is very important [15-17].

Conclusion

With the high rate reduction of the vertiginous episodes frequency and severity, life-style modifications is effective therapy for the common problem of MAV. Satisfactory control of symptoms was achieved in 16 (69,6%) of 23 patients complaining of episodic vertigo in the present study.

Competing interests

The authors declare that they have no competing interests.

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16. Shukla R, Sinh M. Migraine: prophylactic treatment. J Assoc Physicians India 2010;58 (Suppl):26-9.

17. Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia 2011;31(14):1428-38.

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Omer Saglam, Ugur Karapinar, Engin Dursun, Bilal Cetin, Nergis Coskun, Aytug Altundag. The Role of Lifestyle Modifications in the Management of Migraine Associated Vertigo. J Clin Anal Med. 2015;6(6):763-765

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Relationship Between HCV RNA and Serum Alanine Aminotransferase and HCV Genotype Distribution

Dilara Yıldırım 1, Mürşit Hasbek 1, Sevil Alkan 2, Naim Nur 3

1 Sivas Numune Hastanesi, Mikrobiyoloji Laboratuvarı, 2 Sivas Numune Hastanesi, Enfeksiyon Hastalıkları, 3 Cumhuriyet Üniversitesi Tıp Fakültesi Halk Sağlığı AD, Sivas, Türkiye

DOI: 10.4328/JCAM.2369 Received: 27.02.2014 Accepted: 15.04.2014 Published Online: 16.04.2014

Corresponding Author: Dilara Yıldırım, Sivas Numune Hastanesi Mikrobiyoloji Laboratuvarı, Sivas, Türkiye. T.: +90 3462150438 F.: +90 3462221983 GSM: +905327013074 E-Mail: nidimay@gmail.com

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Aim: Hepatitis C virus (HCV) infections is an important health problem all over the world because of inveteracy ratio and causing hepatic failure, cir-rhosis and hepatocellular carcinoma. Our aim in this study is to research HCV RNA in the patients detected anti-HCV positivity with enzyme immunoassay (ELISA) and to analysis the association of HCV RNA in the serum of patients with alanine aminoransferase (ALT) levels and HCV genotypes. Material and Method: In anti-HCV positive patients came from various departments to our laboratory HCV RNA level and genotyping were researched with quanti-tive real time polimerase chain reaction (PCR) Montania 483 (Anatolia Ge-neworks HCV, Turkey) and anti-HCV tests were studied with ELISA (Advia Centaur XP, Germany), ALT results were analysed retrospectively (Olympus AU2700). Results: In 123 of Anti HCV positive 338 serum (%37) were de-tected HCV RNA positivity. In the patients who have ALT level more than 40 (%77.6), HCV RNA is positive. Relationship between HCVRNA positive patients and the patients who have ALT level more than 40 is meaningful. (p<0,05). HCV genotype distribution is detected as genotype 1b %84 (n=37) genotype 1a %11,4 (n=5), genotype 3 %2,3 (n=1), genotype 4 %2.3 (n=1). Discussion: Consequently, in the patients who have hepatic infection with Anti HCV positivity HCV RNA must be researched with molecular methods and viral load must be detected. Genotype results in our study are concordant with our environment. In diagnosis, treatment and follow up of the patients with HCV infection, HCV RNA detection must evaluate totally taking into ac-count HCV genotype and hepatic enzymes.

Keywords: Hepatitis C Virus (HCV); HCV RNA; HCV Genotype; ALT

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Giriş

Hepatit C virus (HCV) enfeksiyonu dünyada yaklaşık 180 milyon kişiyi etkileyen, kronik karaciğer hastalığı, siroz ve hepatosellüler karsinomaya yol açabilen ve batıda KC transplantasyonunun birincil sebebi olan önemli bir sağlık sorunudur [1]

HCV enfeksiyonunun laboratuvar tanısında bugün en çok kullanılan yöntemler ELISA yöntemi ile anti-HCV tespiti, özellikle kronik karaciğer hastalıklarında serum alanin aminotransferazlarının (ALT) değerlendirilmesi ve moleküler yöntemler ile HCV RNA’nın araştırılmasıdır [2,3].

Klinikte HCV RNA, akut enfeksiyonda serokonversiyon öncesinde tanı koymada, antikor oluşturmayan kronik hepatitli hastaların tanısında, yenidoğan enfeksiyonlarının tanısında, antikoru pozitif hastalarda vireminin araştırılmasında ve antiviral tedavinin izlenmesinde kullanılır. Anti-HCV pozitif iken HCV RNA’nın negatif olduğu durumlarda ise, altı ay sonra HCV RNA ve ALT tekrarlanır. Yine HCV RNA negatif ve ALT normal ise HCV enfeksiyonunun iyleştiği söylenebilir. Bunun dışında yalancı ELISA pozitifliği, yalancı HCV RNA negatifliği veya nadiren intermittant yada düşük düzeyde viremi söz konusu olabilir [4].

Hepatit C virüsü diğer RNA virüsleri gibi kolay genomik değişikliğe uğrar. Replikasyon sırasında oluşan hatalar sonucu, kronik hepatit C’li hastalarda HCV’nin farklı genetik sekansları (quasispecies) ile HCV genotiplerini oluşturur. Bu genotip farklılıkları tedavi ve takipteki hastalığın prognozu ve tedavi maliyetindeki önemli belirteçlerdir [5].

Bu çalışmada, mikrobiyoloji laboratuarımıza başvuran ve anti-HCV değeri pozitif olan hastaların, serum HCV-RNA düzeyleri ve ALT düzeyleri arasındaki ilişkinin yanısıra HCV genotiplerinin dağılımının belirlenmesi amaçlanmıştır.

Gereç ve Yöntem

Çalışmaya, Ocak -Aralık 2012 tarihleri arasında Sivas Numune Hastanesi Mikrobiyoloji Laboratuvarına gelen ve anti-HCV pozitif olan hastalardan HCV RNA ve HCV genotip istemi yapılan 338 hasta dahil edildi. Hasta serumlarından Bosphore HCV Quantification Kit v2 (Anatolia GeneWorks, Türkiye) ve Magnesia 16 (Anatolia GeneWorks, Türkiye) otomatik izolasyon cihazı kullanılarak HCV RNA izolasyonu gerçekleştirildi.

Kantitatif HCV RNA tespiti, gerçek zamanlı polimeraz zincir reaksiyonu (RT PCR) yöntemi ile Montania 483 (Anatolia Geneworks HCV, Türkiye) cihazı ile üretici firma talimatlarına uyularak yapıldı.

HCV RNA istemi yapılan ve HCV RNA pozitif 44 hastanın genotip tayini, Bosphore HCV genotip (Anatolia Geneworks Türkiye) kiti kullanılarak, HCV RNA’nın 8 farklı genotipi (1, 1a, 1b, 2, 3, 4, 5, 6) RT PCR yöntemi ile araştırıldı.

Hastaların HCV RNA istemleri ile eş zamanlı belirlenmiş olan serum ALT (Olympus AU2700) düzeyleri hasta dosyaları retrospektif incelenerek kaydedildi. ALT’nin referans üst düzeyi 40 IU/L olarak kabul edildi.

Verilerin girişi ve analizinde SPSS 15.0 Windows programının istatistik ölçütleri kullanıldı. Kategorik karşılaştırmalar iki ortalama arasındaki farkın önemlilik testi ve ki-kare esas alınarak yapıldı.

Bulgular

HCV RNA ve anti HCV çalışılan toplam 338 hasta serumunun 123 (%36,4)’ünde HCV RNA düzeyi pozitif bulundu. 338 hasta içerisinde 289 hastanın ALT düzeylerine retrospektif olarak ulaşıldı. HCV RNA pozitif hastalar içinde ALT düzeyi 40’ın üzerinde olan 59 (%77.6) hasta tespit edildi. HCVRNA pozitif hastalar ile ALT düzeyi 40’ın üzerinde olan hastalar (Tablo_1) arasındaki ilişki anlamlı bulundu ( x²=77.635; p<0.001). HCV RNA genotipleri çalışılan 44 hastanın genotip dağılımına bakıldığında genotip 1b %84 (n=37), genotip 1a %11.4 (n=5), genotip 3 %2.3 (n=1), genotip 4 %2.3 (n=1) olarak tespit edildi (Tablo_2).

Genotiplerini tespit ettiğimiz hastaların serum ALT düzeyleri incelendiğinde, serum ALT düzeyleri ile genotip dağılımı arasında anlamlı bir fark bulunmadı (x²=2,227; p=0.527).

Hasta grubumuzun %56’sını erkekler, %44’ünü ise kadınlar oluştururken, yaş dağılımına bakıldığında erkeklerin yaş ortalamasının 51.93±16, kadınların yaş ortalamasının 52.89±14 olduğu görüldü. Ayrıca HCV RNA pozitif hastaların ALT düzeyleri ile cinsiyet dağılımı açısından cinsiyetler arasında fark vardı. Erkeklere göre kadınların %61.5’inde ALT düzeyi 40’ın altında tespit edildi( x²=12.352; p<0.001). HCV RNA pozitifliği ile cinsiyet dağılımı arasında anlamlı bir ilişki bulunmadı (x²=0.444; p=0.505).

Tartışma

Hepatit C enfeksiyonlarının tanı ve taramasında ELISA yöntemi ile anti-HCV bakılması, kullanımının kolay ve ucuz oluşu nedeniyle ülkemizde ve tüm dünyada ilk tercih edilen testlerdir. Özellikle HCV enfeksiyonu prevelansının % 10’dan düşük olduğu topluluklarda, tarama testlerinde yanlış pozitiflik oranı yüksektir [6,7].

Tarama testlerinde anti-HCV pozitif kişilerde daha spesifik rekombinant immunoblot assay (RIBA), nükleik asid testleri (NAT) veya RT PCR (RT-PCR) HCV RNA’nın doğrulanmasında genellikle kullanılır. Özellikle viral nükleik asitin moleküler yöntemlerle belirlenmesi hastalığın tanısında, tedavi ve prognozunun takibinde önem taşımaktadır [8,9].

Külah ve arkadaşları HCV RNA istemi olan 528 hastada yaptıkları çalışmada HCV RNA pozitif örneklerin %8.6’sında anti-HCV’yi negatif; HCV RNA negatif bulunan hastaların da %52.4’ünde anti-HCV’yi pozitif olarak tespit etmişlerdir. HCV RNA ve anti-HCV birlikte pozitif hastaların %42’sinde; HCV RNA negatif, anti-HCV pozitif hastaların ise %10.6’sında ALT değerleri 50 IU/mL üzerinde saptamışlardır [3].

Hastalığın tedavi ve takibinde farklı duyarlılığa sahip HCV genotiplerinin de önemi vardır. RNA transkripsiyon hataları sonucu ortaya çıkan HCV virusünün altı farklı genotipi ve nükleotid seviyesindeki %31-32 farklılıklardan dolayı subtipleri olduğu saptanmıştır [10,11]. Her genotip ve subtipleri farklı coğrafi dağılım göstermektedir. Genotip 1, 2, 3, tüm dünyada yaygın şekilde görülürken, genotip 4 Ortadoğu ve Afrika’da görülmektedir [12].

Abacıoğlu ve arkadaşları tarafından 89 olgu ile yapılan çalışmada, genotip 1b %75.3, genotip 1a %19.1, genotip 2 %3.4 ve genotip 4 %2.2 oranında bildirilmiştir. Araştırıcılar ayrıca, kronik hepatit C’li hastalarda genotiplere göre serum ALT düzeyleri arasında anlamlı bir fark bulamamışlardır [13].

2008 yılında İzmir’de yapılan ve 345 olguyu içeren Altuğlu ve arkadaşlarının çalışmasında, yine en sık genotip 1b (%87.2) saptanmış, diğer genotiplerin dağılımı ise sırasıyla genotip1a %9.9, genotip 3 %1.4, genotip 2 %0.9 ve genotip 4 %0.6 olarak tespit edilmiştir [14].

Küçüköztaş ve arkadaşlarının kronik hepatit C’li hastalarda yaptıkları çalışmada hastaların %76.9 (n= 40)’unda genotip 1b, %1.9 (n= 1)’unda genotip 1a, %3.8 (n= 2)’inde genotip 2a/2c, %9.6 (n= 5)’sında genotip 3a, %5.7 (n= 3)’sinde genotip 4e, ve %1.9 (n= 1)’unda genotip 4 belirlenmiştir [15].

Çelik ve arkadaşlarının 2010 yılında Sivas’da HCV-PM BIO (Lipa) yöntemi ile yaptıkları çalışmada HCV genotip 1b %88,2 genotip 1a %8,9, genotip 2a %1.12 genotip 3 %1,7 oranında görülmüştür [16].

Ağca ve arkadaşları 2013 yılında Bursa’da 231 hasta ile RT PCR yöntemi ile yaptıkları çalışmada %92,6 genotip 1, %0,4 genotip 2, %3,9 genotip 3, %3,1 oranında genotip 4 bulmuşlardır [17].

Tercan ve arkadaşları 2013 yılında Mersin’de revers hibridizasyon yöntemi ile yaptıkları çalışmada %84.7 oranında genotip 1b, %4.2 genotip 3a, %3.8 genotip 1, %2.1 genotip 1a/1b, %2 genotip 4, %1.7 genotip 1a, %1.3 genotip 2b, %0.4 genotip 2, %0.2 genotip 2a/2c ve ilk olarak ülkemizde %0.4 oranında genotip 6’yı bildirmişlerdir. Genotip 1b olgularının cinsiyet dağılımları ile serum ALT ve HCV-RNA düzeylerinin ortanca değeri arasında istatistiksel olarak anlamlı bir farklılık gözlemlemişlerdir (p< 0.05) [18].

Macaristanda Treso ve arkadaşlarının uyuşturucu kullananlar ve normal populasyon arasında yaptıkları çalışmada birinci grupta HCV genotip 1,3,4 oranlarını sırasıyla %74.2, %22.7, %3, normal popülasyonda genotip 1,3,4 oranlarını sırasıyla %96.6, %2.2, %1.1 olarak belirlemişlerdir. İki grup arasındaki incelemede uyuşturucu kullananlar ve yaşlılarda genotip 3’ün daha yüksek prevelansa sahip ve genotip dağılımlarının değişme eğiliminde olduğu görülmektedir [19].

Bizim çalışmamızda HCV genotip 1b %84.4 oranında görülürken HCV genotip 1a %11.4 genotip 3 ve genotip 4 %2.3 oranlarında görüldü. ALT düzeyi 40’ın üzerinde olan hastalar ile HCV RNA pozitif hastalar arasındaki ilişki anlamlı bulundu (p<0,05). Tüm bu veriler, ülkemizde yaygın olan HCV genotipinin, genotip 1b olduğunu; ALT düzeyi ile HCV RNA arasındaki ilişkinin ve ikinci sıklıkta görülen genotipin ise seçilen hasta grubuna göre değişkenlik gösterebildiğini düşündürmektedir.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

1. Davis GL, Albright JE, Cook SF, Rosenberg DM. Projecting future complications of chronic hepatitis C in the United States. Liver Transpl 2003;9: 331-8.

2. Moretti M, Pieretti B, Masucci A, Sisti D, Rocchi M, Delpretea E. Role of signal-to cutoff ratios in hepatitis C virus antibody detection. Clinical and Vaccine Immunol 2012; 19(8): 1329.

3. Külah C, Cömert FB, Aktaş E, Özlü N, Mengeloğlu Z. Serum ALT düzeyleri, HCV RNA ve anti-HCV arasındaki ilişki. Viral Hepatit Dergisi 2007; 12(3): 116-20.

4. Thomas DL, Lemon SM. Hepatitis C. In: Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 1736-60.

5. Us T, Akgün Y, Kural M. RT-PCR ve üçüncü kuşak ELISA yötemleriyle saptanan HCV-RNA ve anti-HCV sonuçlarının karşılaştırılması. Viral Hepatit Dergisi 2001; (2): 298-301.

6. Centers for Disease Control and Prevention..Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR 2003; 52: 1–13.

7. Oethinger M, Mayo DR, Falcone J, Barua PK, Griffith BP. Efficiency of the Ortho VITROS assay for detection of hepatitis C virus specific antibodies increased by elimination of supplemental testing of samples with very low sample to cutoff ratios. J. Clin. Microbiol 2005; 43: 2477–80.

8. Alter MJ, Kuhnert WL, Finelli L. Guidelines for laboratory testing and result reporting of antibody tohepatitis C virus. Centers for Disease Control and Prevention. MMWR Recomm Rep 2003; 52: 1-13.

9. Simmonds P, Bukh J, Combet C, Deleage G, Enomoto N, Feinstone S. Consensus proposals for a unified system of nomenclature of hepatitis C virus genotypes. Hepatology 2005; 42(4): 962-73.

10. Rosen HR. Clinical practice chronic hepatitis C infection. N Engl J Med 2011;364(25):2429-38.

11. Noorali S, Pace DG, Bagasra O. Of lives and livers: emerging responses to the hepatitis C virus. J Infect Dev Ctries 2011;5(1):1-17.

12.Abacıoglu YH, Davidson F, Tuncer S. The distribution of hepatitis C virus genotypes in Turkish patients. J Viral Hepatit 1995; 2(6): 297-301.

13. Altuglu I, Soyler I, Ozacar T, Erensoy S. Distribution of hepatitis C virus genotypes in patients with chronic hepatitis C infection in Western Turkey. Int J Infect Dis 2008; 12: 239-44.

14. Küçüköztaş MF, Özgüneş N, Yazıcı S. Kronik hepatit C’li hastalarda hepatit C virusu (HCV) genotipleri ile alanin aminotransferaz ve HCV-RNA düzeyleri arasındaki ilişkinin araştırılması. Mikrobiyol Bült 2010; 44: 111-5.

15.Çelik C, Bakıcı MZ, Kaygusuz R, Ertürk R. Sivas yöresindeki HCV genotip dağılımlarının araştırılması. Viral Hepatit Derg 2010; 16(3): 106-10.

16. Ağca H, Mıstık R, Kazak E. Güney Marmara bölgesinde hepatit C virüs genotiplerinin dağılımı. J of Clin and Anal Med 2013; DOI: 10.4328/ JCAM.1954.

17. Tezcan S, Ülger M, Aslan G,Yaraş S, Altıntaş E. Mersin ilinde hepatit C virusu genotip dağılımının belirlenmesi. Mikrobiyol Bült 2013; 47(2): 332-8.

18. Treso B, Takacs M, Dencs A, Dudas M, Par A, Rusvai E. Molecular epidemiology of hepatitis C virus genotypes and subtypes among injecting drug users in Hungary. Euro Surveill 2013; 18(47): 206-39.

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Dilara Yildirim, Mursit Hasbek, Sevil Alkan, Naim Nur. Relationship Between HCV RNA and Serum Alanine Aminotransferase and HCV Genotype Distribution. J Clin Anal Med. 2015;6(6):760-762

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The Prevalence of Obesity in First Year Primary School Students in Nine Districts of İzmir Province

Ebru Turhan 1, Mustafa Tözün 2, Sinem Doğanay 1

1 İzmir Halk Sağlığı Müdürlüğü AR-GE Birimi, 2 İKÇÜ Tıp Fakültesi Halk Sağlığı AD., İzmir, Türkiye

DOI: 10.4328/JCAM.2312 Received: 31.01.2014 Accepted: 11.04.2014 Published Online: 11.04.2014

Corresponding Author: Sinem Doğanay, İzmir İl Halk Sağlığı Müdürlüğü ARGE Birimi, Posta kodu: 35580, İzmir, Türkiye. GSM: +905052510648 F.: +90 2324020033 E-Mail: sinemyagmur@gmail.com

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Aim: Obesity and overweight are defined by the World Health Organization (WHO) as ‘‘abnormal or excessive fat accumulation that may impair health’’. The prevalence of childhood obesity and overweight has been increased worldwide in recent decades. To determine the prevalence of obesity in first year primary school students in nine districts of İzmir province. Material and Method: This study was planned as cross-sectional research, and performed on nine districts selected by simple random method in Izmir province (Aliağa, Beydağ, Dikili, Foça, Güzelbahçe, Kınık, Ödemiş, Seferihisar, Selçuk). The height and the weight figures of each child were noted and Z values were cal-culated with reference to WHO 2007 standards. Children whose Z scores of “height for age” ,”BKİ for age” and “weight for age” are higher than + 2 stan-dard deviation were assessed as tall and obese. In analyzing data Chi-square test and t test were used. Statistical significance value was accepted as p<0.05. Results: The average data and their standard deviation for the chil-dren were as follows: age 6,4± 0,6 years, height 117,0± 6,4 cm and weight 21,5± 4,5kg. According to the anthropometric measurements 3,8% of the children were under-weight (Weight SDS<-2SD), 7,6% were obese (Weight SDS>+2SD) and 3,3% were stunted (height SDS<-2SD). When a comparison is made based on their genders, 8,8% of the male students was found to be obese and 3,2% was stunted whereas 86,3% of the female students was obese and 6,1% was found to be stunted. Discussion: In this study, it was determined that the prevalence of obesity was relatively higher than in the other studies performed in our country. Children should be monitored in fu-ture years and families should be informed about obesity.

Keywords: Obesity; Body Mass Index; School Children; Izmir

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Giriş

Dünya Sağlık Örgütü’ne göre, obezite ve fazla kiloluluk sağlığı bozacak şekilde vücutta anormal ve aşırı yağ birikmesidir. Çocuklarda obezite, 21.yüzyılın en önemli halk sağlığı sorunlarından birisidir. Aşırı kilolu ve obez çocuklarda yetişkinlik döneminde ve genç yaşta, şeker hastalığı ve kalp-damar hastalıkları gibi hastalıkların gelişme olasılığı daha fazladır. Obezite, özellikle düşük ve orta gelirli ülkeleri etkilemektedir. Dünyada 2010 yılında 5 yaş altında yaklaşık 42 milyon aşırı kilolu çocuk olduğu, bunların da 35 milyonunun gelişmekte olan ülkelerde olduğu tahmin edilmektedir [1,2]. Çocuklarda yaş ilerledikçe obezite artmaktadır [2]. Çocukların beslenme ve sağlık durumlarının değerlendirilmesinde kullanılan yaşa göre ağırlık ve boy ölçümleri en güvenilir göstergelerdendir [3, 4]. Yaşa göre ağırlık, iki yaş altı çocuklarda, ağırlık kaybını ve beslenme şeklinin değişmesini en erken gösteren göstergedir [5]. Avrupa’da çocuklarda fazla kilolu ve obez olma prevalansı en yüksek olan ülkeler; İspanya (6-9 yaşta %35,2) ve Portekiz (7-9 yaşta %31,5), en düşük olan ülkeler ise Slovakya (7- 9 yaşta %15,2), Fransa (7- 9 yaşta %18,1), İsviçre (6-9 yaş %18,3) ve İzlanda (9 yaşta %18,5) olarak bulunmuştur [6]. Dünya çapında çocukluk çağı obezite sıklığı hızla artmaktadır [7]. Giderek artan çocukluk çağı obezitesi, tüm dünyada obezite ile mücadele çalışmalarının başlamasına neden olmuştur. Çalışmanın amacı, İzmir iline bağlı dokuz ilçede ilköğretim 1. sınıf öğrencilerinde obezite sıklığının belirlenmesidir.

Gereç ve Yöntem

Çalışma kesitsel tiptedir. İzmir İl Halk Sağlığı Müdürlüğü tarafından Obezite Danışma Birimleri (ODB) kurularak, görev yapan çalışanlara il içinde antropometrik ölçümlerde standardizasyonu sağlamak amacıyla Kasım 2012– Aralık 2012 tarihleri arasında üç günlük eğitim verildi. Antropometrik ölçümlerin nasıl yapılacağı konusunda gruplar bilinçlendirilerek, grupla birlikte uygulamalı antropometrik ölçümler yapıldı. İzmir’e bağlı ilçelerden, basit rastgele örnekleme yöntemi ile 9 ilçe seçildi (Aliağa, Beydağ, Dikili, Foça, Güzelbahçe, Kınık, Ödemiş, Seferihisar, Selçuk). Bu ilçelerin, ilköğretim okullarının, 1.sınıf öğrencilerinin antropometrik ölçümleri ODB çalışanları tarafından okullara gidilerek ölçüldü. Boy ölçümleri ayakta, stadiometre kullanılarak ve baş Frankfort düzleminde iken yapıldı. Vücut ağırlığı, ayakta, kalibrasyonu her gün ölçüm öncesi sabit bir ağırlıkla kontrol edilerek, sert ve düz bir zemin üzerine yerleştirilen dijital tartı aleti ile ölçüldü. BKİ, çocuğun ağırlığının boyunun karesine bölünmesiyle elde edildi [8]. Çocukların yaşa göre ağırlık (YGA) ve yaşa göre BKİ (YG-BKİ) ve yaşa göre boy Z skorları (YGB) WHO’nun 2007 yılı referans değerlerine göre hesaplandı [9]. Z- skoru karşılaştırma yapılan antropometrik ölçümlerin referans nüfusun ortanca (medyan) değerinden kaç standart sapma altında veya üstünde olduğunu ifade eder [10].

Z skoruna göre referans grubun ortanca değerinden (-2SD ve altı) aşağıda olan çocuklar düşük kilolu, zayıf ve kısa (bodur), (+2 SD ve üstü) üstünde olan çocuklar obez ve uzun boylu olarak sınıflandırıldı, aradaki grup normal kilolu ve normal boylu olarak değerlendirildi. İkili karşılaştırmalarda, YGA ve YG-BKİ Z skorlarına göre obez olanlar ve normal olanlar olarak, YGB’ye göre bodur olanlar ve normal olanlar olarak birleştirilerek değerlendirildi. İzmir’e bağlı ilköğretim birinci sınıf öğrencilerinin sayısı 47870’dir. Bu öğrenciler araştırma evreni olarak kabul edildi. Çocuklarda obezite prevalansı %20 kabul edilerek, tolerans değeri 0.01 alınarak, %95 güven düzeyinde örneklem büyüklüğü 5448 olarak saptandı. İlköğretim birinci sınıfa giden tüm öğrencilere ulaşılmaya çalışıldı. Ulaşılan, 6445 çocuktan 254’ünün boy, ağırlık ve doğum tarihi eksik olduğu için 6191 çocuk çalışmaya alındı. Çalışmanın yapılabilmesi için İzmir İl Halk Sağlığı Müdürlüğü tarafından İzmir İl Milli Eğitim Müdürlüğü’nden gerekli olan izin alındı (31.08.2012 tarih 134/27 sayı). Verilerin analizinde, kategorik değişkenler yüzde olarak, sürekli değişkenler ortalama± standart sapma olarak verildi. Kategorik değişkenlerin karşılaştırılmasında Ki-kare testi, sürekli değişkenlerin karşılaştırılmasında t testi kullanıldı. İstatistiksel analizler SPSS 16.0 istatistik programı ile gerçekleştirildi.

Bulgular

Çocukların %49,4’ü kız (3058), %50,6’sı (3133) erkektir. Çocukların %57,5’i 6, %42,5’i 7 yaşındadır. Çalışmaya katılan çocukların yaş ortalaması 6,4’tür. Erkeklerle kızlar arasında yaşları açısından anlamlı fark saptanmadı (p=0,213). Ancak erkeklerin ağırlık (22,4± 4,6), boy (118,3± 6,4) ve BKİ (15,9± 2,4) ortalamaları; kızların ağırlık (21,5± 4,5), boy (117,0± 6,4), BKİ (15,7± 2,5) ortalamalarından anlamlı olarak yüksek saptandı (p<0,001) (Tablo 1). Çalışmaya alınan çocukların, YGB Z skoru ortalaması 0,48± 1,15, YGA Z skoru ortalaması (0,11± 1,26), YG-BKİ Z skoru ortalaması 0,07± 1,47 olarak bulundu. YGA’a bakıldığında obezite sıklığı toplamda %7,6, erkeklerde %8,8, kızlarda %6,3 saptandı ve aralarındaki fark anlamlı bulundu (p<0,001). YG-BKİ’ne bakıldığında obezite sıklığı toplamda %8,8, erkeklerde %10,4, kızlarda %7,1 saptandı. YG-BKİ’ye göre, obezite sıklığı erkeklerde, kızlara göre anlamlı olarak fazladır (p<0,001).

Araştırmada, çocuklarda obezite sıklığı 6 yaşında %7,9, 7 yaşında %10,0’dır. Erkeklerde yaşlara göre (%9,2; %12,1) obezite görülme sıklığı kızlardan (%6,6; %7,8) anlamlı olarak daha fazla saptandı (p<0,05).

Araştırmada, YGA’ya göre düşük kiloluluk %3,8, YG-BKİ’ye göre zayıflık %5,8 saptandı. Bu çalışmada YGA’ ya göre düşük kiloluluk erkeklerde %3,7, kızlarda %4,0 iken YG-BKİ’ye göre zayıflık erkeklerde %5,5, kızlarda %6,2 bulundu.

Çocukların, YGB’na bakılarak, toplamda %3,3 çocuğun bodur (kısa) olduğu belirlendi. (Tablo 2,3). Erkeklerin %3,2’sinde, kızların %3,4’ünde bodurluk (kısalık) saptandı ancak aralarındaki fark anlamlı değildi (p>0,05).

YGB’ye göre bodur olan çocuklarda, YGA Z skoru ortalaması (-1,39± 1,097), bodur olmayan çocuklardan (0,16± 1,241) anlamlı olarak düşük saptandı (p<0,05). YGA’a göre obez olma; bodur olan çocuklarda (%0,5), olmayanlara (%7,8) göre anlamlı olarak daha düşük bulunmuştur (p<0,001).

İlçelerde, YG-BKİ’ye göre obezite sıklığı Aliağa’da %9,9, Beydağ’da %5,1, Dikili’de %10,5, Foça’da %6,4, Güzelbahçe’de %12,8, Kınık’ta %6,7, Ödemiş’te %8,5, Seferihisar’da %8,4, Selçuk’ta %5,5 saptandı. YGA’ya göre obezite sıklığı Aliağa’da %6,8, Beydağ’da %5,6, Dikili’de %8,5, Foça’da %6,4, Güzelbahçe’de %11,5, Kınık’ta %3,7, Ödemiş’te %8,3, Seferihisar’da %10,3, Selçuk’ta %4,4’ tür. Obezite sıklığı YG-BKİ’ye ve YGA’ya göre en fazla Güzelbahçe’de (%12,8; %11,5) iken YG-BKİ’ye göre en az Beydağ’da(%5,1); YGA’ya göre en az Kınık’ta (%3,7) saptandı. Kısalık ise en fazla Kınık’ta (%5,5), en az Foça’da (%0,7) saptandı.

Tartışma

Araştırmada, 6-7 yaş erkeklerin ağırlık ortalamaları sırasıyla 21,5± 4,1, 23,5± 4,9 iken, Gemlik’te 2001 yılında 6-12 yaş 4487 çocukta yapılan çalışmada 6-7 yaş erkeklerin ağırlık ortalamaları 22,5± 3,5, 24,4± 4,7’dir. Çalışmada 6-7 yaş kızların ağırlık ortalamaları sırayla 20,8± 4,2, 22,6± 4,6 iken Gemlik’te yapılan bir çalışmada 6-7 yaş kızların 21,6± 3,5, 23,8± 4,8’dir [11]. Araştırmada Gemlik’te yapılan çalışmaya göre erkek ve kızların ağırlık ortalamaları daha düşük saptandı. Pakistan’da 2012 yılında 5-12 yaş 1860 çocukla yapılan çalışmada 6- 7 yaş erkeklerin ağırlık ortalamaları 21,6± 5,0, 23,5± 5,1 iken kızların 21,0± 4,9, 24,0± 5,5’dir. Pakistan’da yapılan çalışma ile bu çalışmada erkek ve kızların ağırlık ortalamaları benzerdir [4]. Türkiye genelinde 2011 yılında yapılan TOÇBİ çalışmasında (6-10 yaş, 2008-2009 yılı, 1-4 sınıf 11387çocuk) 6- 7 yaş erkeklerin ağırlık ortalamaları sırasıyla 22,9± 3,6, 24,1± 4,9, kızların ağırlık ortalamaları 22,4± 4,2, 23,4± 5,3’tür. Çalışmada erkek ve kızların tüm yaş gruplarında ağırlık ortalamaları TOÇBİ çalışmasından [2] ve Mardin’de [12] yapılan çalışmadan düşük saptandı. Bu farklılığın, yaş gruplarının farklı olmasından kaynaklanıyor olabileceği düşünüldü.

Araştırmada 6- 7 yaş erkeklerin BKİ ortalamaları sırasıyla 15,8± 2,3, 16,0± 2,6 iken Pakistan’da yapılan araştırmada 15,3± 2,8, 15,5± 2,4 saptanmıştır. Ağırlık ortalamalarında olduğu gibi 6- 7 yaş BKİ ortalamaları da birbirine yakındır. Çalışmada 6- 7 yaş kızların BKİ ortalamaları sırasıyla 15,6±2,5, 15,8±2,5 iken Pakistan’da yapılan çalışmada 14,7± 2,4, 15,5± 2,7 olarak saptanmıştır [6]. Çalışmada 6- 7 yaş kızların BKİ değer ortalamaları Pakistan’da yapılan çalışmadan yüksek saptandı. Elazığ’da 2007 yılında 6-11 yaş 3342 çocukla yapılan araştırmada 6- 7 yaş erkeklerin BKİ ortalamaları sırasıyla 15,9± 1,7, 15,8± 1,7 iken kızların BKİ ortalamaları 22,6± 3,0, 24,1± 3,5 saptanmıştır. Elazığ’da yapılan çalışmada erkeklerin BKİ ortalamaları çalışmaya benzer iken kızlarda tüm yaş gruplarında daha yüksekti [13].

Araştırmada YG-BKİ’ye göre obezite sıklığı %8,8 saptandı. TOÇBİ araştırmasında YG-BKİ’ye göre obezite sıklığı %6,5 olarak bildirilmiştir. Kanada’da, 2005 yılında 1026 okul öncesi çocukla yapılan araştırmada, YG-BKİ’ye göre obezite sıklığı %11,3 [14], Mardin’de 7-15 yaş 3460 çocukla yapılan araştırmada obezite sıklığı %10.57 olarak saptanmıştır [15]. Kanada’da yapılan çalışmada obezite sıklığı daha fazladır. Ancak aynı ülkede, Mardin’de bile obezite sıklığının fazla olması, yeme alışkanlıklarının farklı olabileceğini düşündürterek, obezite de bölgesel farklılığın olabileceğini akla getirdi. Farklı yaş gruplarının çalışmalarda ele alınması da, obezite sıklığındaki farklılığı açıklayabilmektedir diye düşünmekteyiz.

Araştırmada YGA’ye göre obezite sıklığı %7,6’dır. TOÇBİ çalışmasında YGA’ya göre obezite sıklığı %4,9’dur [2], çalışmamızda obezite sıklığı daha yüksektir. Bunun nedeni İzmir’in sosyoekonomik yönden daha yüksek olmasından kaynaklanıyor olabilir. Kırıkkale’de 2007 yılında 6-14 yaş arası 501 çocukla yapılan çalışmada YGA’ya göre obezite sıklığı %5,4’tür [16]. Tayland’ta 2011 yılında 2-10 yaş 4610 çocukla yapılan araştırmada obezite sıklığı %8,3 olarak bildirilmiştir. Bu çalışmamıza benzer bir sıklıktır.

Araştırma grubunda YG-BKİ ve YGA’ya göre erkeklerde obezite prevalansı (%10,4; %8,8), kızlara göre (%7,1; %3,4) anlamlı olarak yüksek bulundu. TOÇBİ ve Kanada’da yapılan çalışmalarda da erkeklerde obezite (%7,5; %11,7) kızlardan (%5,4; %10,8) daha fazla saptanmıştır [2, 14].

Araştırmada çocuklarda obezite sıklığı 6 yaşında %7,9, 7 yaşında %10,0’dır. Erkeklerde yaşlara göre (dağılım %9,2; %12,1) obezite görülme sıklığı, kızlardan (dağılım %6,6; %7,8) anlamlı olarak daha fazla saptandı. TOÇBİ çalışmasında çocuklarda obezite görülme sıklığı 6 yaşında %5,5, 7 yaşında %5,8 bulunmuştur. Yaşın artmasıyla birlikte obezite sıklığının artığı görülmektedir [2].

Araştırmada YGA’ya göre düşük kiloluluk %3,8 saptandı. Manisa’da 2007 yılında 6-14 yaş 1018 çocukla yapılan çalışmada YGA’ya göre düşük kiloluluk %4,12 saptanmıştır [17]. Kırıkkale’de yapılan araştırmada düşük kilolu olma sıklığı %1,6 saptanmıştır [16]. Araştırmada düşük kilolu olma Manisa’da yapılan çalışma ile benzer iken, Kırıkkale’de sıklık daha azdır. TOÇBİ çalışmasında YGA’ya göre düşük kilolu olma sıklığı %2,4 saptanmıştır [2]. Tayland’ta yapılan çalışmada 2-10 yaş çocukların %27,8’inde düşük kiloluluk saptanmıştır [18]. Bu çalışmadaki sıklıktan oldukça farklıdır. Yaş grubunun ve bölgesel farklılıkların etkisi olmuş olabilir.

Bu çalışmada, YGA’ ya göre düşük kiloluluk erkeklerde %3,7, kızlarda %4,0 iken YGBKİ’ye göre zayıflık erkeklerde %5,5, kızlarda %6,2 bulundu. TOÇBİ çalışmasında YGA’ya göre düşük kiloluluk erkeklerde %2,0, kızlarda %2,7; YG-BKİ’ye göre zayıflık erkeklerde %1,3, kızlarda da %1,3 saptandı. Bu çalışmada düşük kiloluluk durumu TOÇBİ çalışmasından daha yüksektir. Kızlarda düşük kiloluluk, erkeklerde şişmanlık sorun olarak gözükmektedir [2].

Çalışmada, kızlarda YGB’ye göre bodurluk (%3,4), erkeklerden (%3,2) fazla bulundu ancak aralarındaki fark anlamlı değildi (p=0,75). TOÇBİ çalışmasında da, kızlarda YGB’ye göre bodurluk (%5,2), erkeklerden (%4,9) daha fazla saptanmıştır [2]. Ankara Park Sağlık Ocağı bölgesinde 7-15 yaş 392 çocukla 2005 yılında yapılan araştırmada kızlarda bodurluk (%14,7) erkeklerden (%10,9) daha fazla saptanmış ancak aralarındaki fark anlamlı bulunmamıştır [19]. Manisa’da yapılan çalışmada bodurluk sıklığı %7,46, Kırıkkale’de %1,8, Ankara Park Sağlık Ocağı Bölgesi’nde yapılan çalışmada %12,8, Kars’ta 7-14 yaş 143 çocukla 2012 yılında yapılan çalışmada %2,82, saptanmıştır [16, 17, 19, 20]. Bu çalışmada, TOÇBİ ve Ankara Park Sağlık Ocağı Bölgesi’nde yapılan çalışmalara göre bodurluğun daha az saptanmasının nedeni beslenme durumunun İzmir’deki çocuklarda daha iyi olmasından kaynaklanabilir. Kars ilindeki çalışmada bodurluğun düşük çıkmasının nedeni ise, sosyoekonomik yönden daha iyi ve özel okulda okuyan öğrencilerin alınmasından olabilir. Tayland’ta yapılan bir araştırmada 2-10 yaş çocuklarda bodurluk sıklığı %19,9 saptanmıştır. Tayland’ta bu çalışmaya göre daha fazla bodurluk saptanmıştır. Bodurluğu saptama yönteminin farklı olmasından ve farklı bölgelerde yapılmasından kaynaklanabilir [18].

Araştırmada YGA’a göre obez olma, bodur olan çocuklarda (%0,5) olmayanlara (%7,8) göre anlamlı olarak daha düşük bulundu (p<0,001). Manisa’da yapılan çalışmada boya göre ağırlık değerlerine göre şişmanlık, kısa boylu olan çocuklarda (%5,4), olmayanlara göre (%8,6) daha az bildirilmiştir [17].

İlçelere göre en fazla obezite Güzelbahçe’de (%12,8) görülmüştür. En çok bodurluk Kınık’tadır (%5,5). Narlıdere’de yapılan bir araştırmada ise bodurluk sıklığı %4,1 saptanmıştır [21]. Obezite sıklığı, Aliağa (%9.9) ve Foça (%6.4) gibi birbirine yakın ve benzer sosyoekonomik özellikleri olan ilçelerde farklı olduğu gibi Güzelbahçe (%12.8) ve Beydağ (%5.1) gibi birbirinden uzak ve sosyoekonomik yönden birbirine benzemeyen ilçelerde de farklılık göstermektedir. Bu durum, obeziteyi etkileyen değişik faktörlerin olduğunu düşündürmektedir. Genetik, doğum öncesi, doğum sonrası ve çevresel etmenlerin büyüme üzerine etkisi her toplumda farklılık göstermektedir. Boy kısalığında da genetik etmenler önem taşır. Boy kısalığı yapan etiyolojik etmenlerinin dağılımında da ülkeden ülkeye, hatta aynı ülke içinde bölgesel farklılıklarda gösterebilmektedir (12, 22). Bunların hangisinden kaynaklandığını saptamak için daha ileri girişimsel çalışmaların yapılmasına gereksinim vardır.

Sonuç ve Öneriler

Araştırmada, çocuklarda obezite sıklığı diğer çalışmalardan biraz daha yüksek saptandı. Erkeklerde obezite sıklığı, kızlara göre anlamlı olarak fazladır. İlçelere göre bakıldığında çok farklı obezite sıklıkları saptandı. Kısa çocuklarda, BKİ’ye göre obezitenin, kısa olmayan çocuklara göre anlamlı olarak fazla olduğu görüldü. Çocuklarda obezitenin azaltılması için bu yaş grubu çocuklar gelecek yıllarda da takip edilmeli, yeme alışkanlıkları sorgulanmalı, yıllara göre obezite sıklığının değişimi incelenmeli, aileler obezite konusunda bilinçlendirilmelidir.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

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Ebru Turhan, Mustafa Tozun, Sinem Doganay. The Prevalence of Obesity in First Year Primary School Students in Nine Districts of Izmir Province. J Clin Anal Med. 2015;6(6):755-759

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In Primary Health Care Childhood Immunization Services Costs, Practices

Zeynep Türk 1, Özgür Türk 2

1 Halk Sağlığı Müdürlüğü, Osmangazi Üniversitesi Aile Hekimliği Birimi, Eskişehir, 2 Sivrihisar Devlet Hastanesi Genel Cerrahi Kliniği, Sivrihisar, Türkiye

DOI: 10.4328/JCAM.2394 Received: 09.03.2014 Accepted: 11.04.2014 Published Online: 11.04.2014

Corresponding Author: Özgür Türk, Sivrihisar Devlet Hastanesi Genel Cerrahi Kliniği, Sivrihisar, Eskişehir, Türkiye. GSM: +905054403377 E-Mail:drozgurturk@gmail.com

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Abstract

Human health has became a topic that is required exploration and develop-ment since the existence of humanity. Many of the diseases out of during the human life and with the miscellaneous invention; solution ways were sought. Development of antibiotics and vaccines are featured inventions in this war-fare. Vaccine is known as the best alternative and may be primarily pre-ferred method. Study was conducted to determine of costs and comparison of estimates of the families. In order to investigate the prediction of family about cost and vaccine applications a survey prepared that is reached with a link to the survey on the internet and 170 people participated. According to 2013 childhood immunization schedule; 21 doses of vaccine are adminis-tered for 13 varieties of disease. While in the market price of vaccines were identified as TL1094.54 Ministry of Health vaccine price is TL320.22 for a child. Families vaccinated or have been vaccinated their 98% of children to the family physicians or health care facilities. Primarialy reasons of fami-lies to prefer primary health care as a priority are vaccines stored in safer conditions and better monitoring of the vaccination time in family physician system. When the cost of immunization that is primary of protective health services analysed significant differences between the ministry prices with the market price is present, families are not aware enough about these costs have been identified.

Keywords: Vaccine Cost; Vaccination; Primary Care

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Giriş

Sağlığın teşviki ve geliştirilmesi bağlamında sağlık, soyut bir durumdan çok fonksiyonel terimlerle anlatılabilen bir sonuca ulaşma aracıdır. İnsanların bireysel, sosyal ve ekonomik olarak verimli bir yaşam sürmesine izin veren bir kaynaktır. İnsanlar mikroorganizmalarla dolu bir dünyada yaşamaktadırlar. Sık karşılaşılan mikroorganizmalarla yaşarken tıbbın buluşu olan antiseptikler, antibiyotikler ve aşılar bu savaşta kullanılmaktadır. Bağışıklama, bebekleri, çocukları ve erişkin bireyleri aşılayarak hastalıklardan korumak amacıyla yürütülen çok önemli temel sağlık hizmetidir [1]. Aşılama çalışmaları hastalıkların, sakatlıkların ve ölümlerin önlenmesinde önemli bir yer tutar. Bu hizmetler sağlık alanında yapılan önemli yatırımlardan biridir. Son yıllarda gelişen teknoloji sayesinde çocuklara önerilen aşıların sayısı hızla artmıştır [2]. Enfeksiyon hastalıkları ile savaşta aşılama en güvenli, en etkili ve en iyi tıbbi yaklaşım olarak bilinir. Çünkü aşılama sadece aşılanan kişiyi hastalıktan korumakla kalmayıp, aynı zamanda o hastalığın kontrol altına alınmasını sağlar. Hükümetler yeni geliştirilen aşıların ücretsiz aşı programlarına alma konusunda karar vermek zorundadır. Ulusal aşı takvimine bir aşının eklenmesine karar verebilmek için öncelikle ilgili hastalığın bir halk sağlığı sorunu olup olmadığı sorgulanmalıdır [3]. Eğer bu soruya olumlu yanıt verilirse aşılamanın en iyi yöntem olup olmadığı belirlenmeli, bu aşının takvime eklenmesinin getireceği maliyetin yanı sıra, bağışıklamanın her bireye ulaştırılabilirliği ve sürekliliği sağlanmalıdır. Ülkemizde sağlık sektörü 1980 ‘li yılların başlarından itibaren, dünyadaki genel eğilimlere paralel olarak değişim sürecine girmiş ve son 10 yıldır bu değişimin hızı artmıştır. Geçmiş yıllara bakıldığında; çocukluk çağı hastalıklarından ölüm ve sakatlık oranı fazla iken günümüzde bu oranlar azalmıştır[4]. Bu gelişmeye sebep, koruyucu sağlık hizmetlerine verilen önemin artması ve Genişletilmiş Bağışıklama Programıdır.

1980’li yılların başında Ulusal Aşı Takvimi’ne göre; Verem, Difteri, Boğmaca, Tetanoz, Oral Polio, Kızamık ve Çiçek aşısı olarak toplam 7 hastalık için yapılan 16 dozluk bir aşı programı uygulanıyordu. Günümüzde ise son eklenen Suçiçeği ve Hepatit A aşısı ile birlikte Hepatit B, Verem, Difteri, Aselüler Boğmaca, Tetanoz, İnaktif Polio, Hemofilus İnfluenza Tip B, Konjuge Pnömokok, Kızamık, Kızamıkçık, Kabakulak’a yönelik 13 çeşit hastalık için toplam 21 doz aşı uygulanmaktadır [5]. Sağlık Bakanlığı’nın aşı takvimine eklediği son eklenen aşılarla çocukluk çağında uygulanacak takvim dışı aşı neredeyse kalmamıştır. [6]. Gelişen tıbbi çözümlerle artan aşı sayısı, maliyet konusuda önem kazanmıştır. Eklenen son aşılarla birlikte maliyetin daha da arttığı bilinmektedir. Bu çalışma, 2013 yılı aşı takviminde bulunan aşıların Çocukluk çağı boyunca maliyetinin ne kadar olduğunu tespit etmek, aşı takviminde bulunan aşıların piyasa değerlerini araştırmak ve ailelerin de bu konudaki fikirlerini değerlendirmek amacıyla yapılmıştır.

Gereç ve Yöntem

Çocukluk çağı aşı takvimine göre belirlenen aşıların maliyetleri Sağlık Bakanlığı alım fiyatlarına ve piyasa değerine göre hesaplanmıştır. Ailelerin bu konudaki düşüncelerinin araştırılması amacıyla anket soruları hazırlanmış ve internet üzerinden bir linkle ulaşılır ankete 194 kişi katılmıştır. 24 kişi sadece demografik özellik bilgileri vermiştir, bu nedenle bu kişiler değerlendirmeye alınmamıştır. 170 kişi bu konularla ilgili cevap verdiğinden dolayı yapılan analizler bu kişiler üzerinden değerlendirilmiştir. İstatistiksel analiz için, SPSS 16.0 programı kullanılmıştır. Ki-kare testi uygulanarak analizleri yapılmıştır.

Anket Soruları

Soru 1: Cinsiyetiniz nedir?

Soru 2: Yaşınız kaç?

Soru 3: Eğitim durumunuz nedir?

Soru 4: Aylık ailenizin hane gelir aralığı nedir?

Soru 5: Hangi meslek grubundasınız?

Soru 6:Kaç çocuğunuz var ve yaşları nelerdir?

Soru 7: Çocuğunuzun aşılarını nerede yaptırıyorsunuz/yaptırdınız?

Soru 8:Aşılama hizmetini almak için sağlık bakanlığı birinci basamak sağlık kuruluşlarını tercih etmenizde aşağıdakilerden hangileri etkilidir?

Soru 9: Çocuğunuzun bağışıklama işlemleri ile ne derecede ilgilisiniz?

Soru 10: Birinci basamakta uygulanan aşıların yeterli olduğuna katılıyor musunuz?

Soru 11: Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki farkı nasıl değerlendiriyorsunuz?

Soru 12: Aşıların maliyeti aşı yaptırma kararınıza etkili midir?

Soru 13: Sağlık Bakanlığı aşılama takviminde olan aşıların maliyeti ile ilgili tahmininizi aşağıdaki tablodan işaretler misiniz?

Soru 14: Çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti sizce ne kadardır?

Bulgular

Sağlık Bakanlığı’nın 2013 yılında uyguladığı aşı takvimine göre; sıfır, bir, altıncı aylarda olmak üzere üç doz Hepatit-B aşısı; iki, dört, altıncı ve onsekizinci aylarda olmak üzere dört doz DaBT-İPA-Hib aşısı, ikinci ayda olmak üzere bir doz BCG aşısı, iki, dört, altıncı ve onikinci aylarda olmak üzere dört doz Konjuge Pnömokok aşısı, altıncı ve onsekizinci aylarda olmak üzere iki doz Oral Polio aşısı, onikinci ayda ve İlköğretim birinci sınıfta olmak üzere iki doz KKK (Kızamık-Kızamıkçık-Kabakulak) aşısı, onikinci ayda olmak üzere bir doz Suçiçeği aşısı, onsekizinci ve yirmi dördüncü aylarda olmak üzere iki doz Hepatit-A aşısı, İlköğretim birinci sınıfta olmak üzere DaBT-İPA ve İlköğretim sekizinci sınıfta olmak üzere bir doz Td aşısı ile toplam yirmi bir doz aşı uygulanmaktadır. Sağlık Bakanlığı’nın alım fiyatlarına göre hesaplamaları yapılan 21 doz çocukluk çağı aşısının toplam maliyeti 320.22 TL’dir (Tablo 1).

Sağlık Bakanlığı’nın 2013 yılında uyguladığı aşı takvimine göre; sıfır, bir, altıncı Aylarda olmak üzere 3 doz Hepatit-B aşısı; iki, dört, altıncı ve onsekizinci aylarda olmak üzere dört doz DaBT-İPA-Hib aşısı, ikinci ayda olmak üzere bir doz BCG aşısı; iki, dört, altıncı ve onikinci aylarda olmak üzere Konjuge pnömokok aşısı; altıncı ve onsekizinci aylarda olmak üzere iki doz Oral Polio aşısı, onikinci ayda ve İlköğretim birinci sınıfta olmak üzere iki doz KKK(Kızamık-Kızamıkçık-Kabakulak) aşısı, onikinci ayda olmak üzere bir doz Suçiçeği aşısı, onsekizinci ve yirmi dördüncü aylarda olmak üzere iki doz Hepatit-A aşısı; İlköğretim birinci sınıfta olmak üzere DaBT-İPA ve İlköğretim sekizinci sınıfta olmak üzere bir doz Td aşısı ile toplam yirmi bir doz aşı uygulanmaktadır. Piyasa değeri bulunamayan Oral Polio dışındaki toplam yirmi adet aşının piyasa değerine göre hesaplamaları yapılmış ve 1094.54 TL olarak Çocukluk çağı aşı maliyeti çıkmıştır (Tablo 2).

Yapılan çalışmada 26-35 yaş arası grup ile birinci basamakta uygulanan aşıların yeterlilik durumu arasında önemli derecede bir ilişki vardır (P<0.05). (Tablo 3)

Katılımcıların eğitim durumu ile Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki fark değerlendirmesi arasında önemli derecede bir ilişki vardır. (P<0.05). (Tablo 4)

Katılımcıların meslek grubu ile birinci basamakta uygulanan aşıların yeterli olup olmaması arasında pozitif bir ilişki vardır. (P<0.05). (Tablo 5)

Katılımcıların meslek grubu ile Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki farkın değerlendirilmesi arasında çok önemli düzeyde bir ilişki vardır. (P<0.05). (Tablo 6)

Katılımcıların meslek grubu ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında önemli bir ilişki vardır (P<0.05). (Tablo 7). Aşıların maliyetinin aşı yaptırma kararına etkisi ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında bir ilişki yoktur (P<0.05). Katılımcıların aylık hane geliri ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında bir ilişki yoktur (P<0.05). Katılımcıların aylık hane geliri ile aşıların maliyetinin aşı yaptırma kararına etkisi arasında bir ilişki yoktur. (P<0.05)

Tartışma

2012 yılından sonra Sağlık Bakanlığı Aşı Takvimine Hepatit-A ve Suçiçeği Aşısı eklenmiştir [7]. Bu eklenen aşılarla birlikte Çocukluk çağı aşı takviminde onüç ayrı hastalık için yirmi bir dozluk aşı uygulanmaktadır [8,9] . Çocukluk çağı boyunca bir çocuğa uygulanan aşıların maliyetini Sağlık Bakanlığı ve piyasa değerine göre hesaplamak ve ailelerin bu konu ile ilgili düşüncelerini öğrenmek ve karşılaştırmak amacıyla yapılan çalışmada; Sağlık Bakanlığı’nın alım fiyatlarına göre hesaplamaları yapılan Çocukluk Çağı aşısının toplam maliyeti 320.22 TL’dir. Piyasa değeri bulunamayan Oral Polio dışındaki Çocukluk çağı aşı takvimine göre belirlenen toplam yirmi adet aşının piyasa değerine göre hesaplamaları yapılmış ve 1094.54 TL olarak Çocukluk çağı aşı maliyeti çıkmıştır. Çocukluk çağı aşı takvimine göre belirlenen aşıların maliyetleri Sağlık Bakanlığı alım fiyatlarına ve piyasa değerine göre hesaplanmıştır. Ailelerin bu konudaki düşüncelerinin araştırılması amacıyla ondört soruluk anket hazırlanmış ve internet üzerinden bir linkle ulaşılan anketi 170 kişi cevaplamıştır. Ki-kare testi uygulanarak analizleri yapılmıştır. Ankete katılan 170 katılımcının 55 ‘i erkek ve 115’i kadındır. Ankete katılan 170 katılımcıdan altı kişi 19-25 yaş Aralığında, 76 kişi 26-35 yaş Aralığında, 76 kişi 36-45 yaş aralığında ve 12 kişi 46 yaş ve üstü aralığındadır. Genç kadın grubunun yoğun katıldığı bir çalışma olmuştur. Ankete katılan 170 katılımcıdan İlkokul ve Altı eğitimi olan dört kişi, Ortaokul mezunu olan dokuz kişi, Lise mezunu olan 30 kişi, Üniversite mezunu olan 98 kişi, Lisansüstü veya Doktora eğitimi almış olan 28 kişi vardır. Üniversite mezunu katılımcının daha yoğun olduğu bir çalışma olmuştur.

Ankete katılan 170 katılımcıdan 1000 TL ve altı aylık hane geliri olan 8 kişi, 1001-2000 TL aylık hane geliri olan 18 kişi, 2001-3000 TL aylık hane geliri olan 37 kişi, 3001-4000 TL aylık hane geliri olan 44 kişi, 4001 TL ve üstü aylık hane geliri olan 63 kişi vardır. Katılımcıların çoğunluğunun gelir seviyesi 4001TL ve üstü geliri olan gruplardır.

Ankete katılan 170 katılımcının 67’si Sağlık çalışanı, 14’ü memur, 25’i diğer kamu çalışanı, 24’ü özel sektör çalışanı, 17’si ev hanımı, 16’sı öğretmen, 7’si işçidir. Çocuğunuzun aşılarını nerede yaptırıyorsunuz/yaptırdınız? Sorusuna; Ankete katılan 170 katılımcıdan 155’i çocuklarının aşılarını aile hekimliği ya da sağlık ocağında yaptırmış veya yaptırmaktadırlar, 15 kişi ise özel hastane veya muayenehanede yaptırmış ya da yaptırmaktadırlar. Aileler çocuklarının aşılarını yüksek oranda birinci basamakta yaptırmaktadır. Katılımcıların aşılama hizmetini almak için Sağlık Bakanlığı birinci basamak sağlık kuruluşlarını tercih etmelerindeki etkiler araştırıldığında; birden fazla seçeneğin işaretlenebildiği bu soruda ankete katılan 170 katılımcıdan 96 ‘sı birinci basamak sağlık kuruluşlarını seçme tercihi olarak aşıların daha güvenli şartlarda saklanmasını ve yine 96 kişi aile hekimliği sistemiyle aşı zamanlarının daha iyi takip edilmesini seçerek 1.tercih sebebi olarak belirlemiştir. 75 kişi sağlık personelinin daha tecrübeli olmasını tercih sebebi olarak belirtmiştir. 64 kişi aşıların ücretsiz olmasını tercih sebebi olarak belirtmiştir. 37 kişi bekleme süresinin az olmasını tercih etmiştir. Kişilerin tercih sebeplerinde güven ve ilginin ön planda olduğu ve bunda aile hekimliği sisteminin etkisi olduğu tespit edilmiştir. Aşıların ücretsiz olmasının tercih için öncelik olmadığı ortaya çıkmıştır. Ankete katılanlara çocuklarının bağışıklama işlemleri ile ilgi dereceleri sorulduğunda; ankete katılan 168 katılımcıdan 109’u çocuğunun bağışıklama işlemleriyle kesinlikle ilgili olduğunu , 54’ü ilgili olduğunu, dört kişi kararsız olduğunu ve bir kişide hiç ilgili olmadığını belirtmiştir. Katılımcıların büyük çoğunluğu ilgili olduklarını belirtmişlerdir. Katılımcılara birinci basamakta uygulanan aşıların yeterliliği sorulduğunda; Ankete katılan 170 kişinin 47’si birinci basamakta uygulanan aşıların yeterli olduğuna kesinlikle katılıyor, 93’ü yeterli olduğunu düşünüyor. 17’si kararsız iken 13’üde aşıların yeterli olmadığını düşünüyor. Katılımcıların büyük çoğunluğu aşıların yeterli olduğunu belirtmişlerdir.

Ankete katılanlara Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki farkı değerlendirmeleri istendiğinde; Ankete katılan 165 kişiden 42’si aşı fiyatlarıyla ilgili olarak aşıların piyasada çok pahalı olduğunu düşünüyor, 102’si piyasada pahalı olduğunu düşünüyor, 18’i fark olmadığını düşünüyor, iki kişi Sağlık Bakanlığı fiyatlarının pahalı olduğunu düşünüyor, bir kişi ise Sağlık Bakanlığı fiyatlarının çok pahalı olduğunu düşünüyor. Genel olarak katılımcılar piyasada pahalı olduğunu düşünüyor. Ankete katılanlara aşıların maliyetinin aşı yaptırma kararına etkisi sorulmuş. Bu soruda ankete katılan 166 kişiden 12 kişi aşıların maliyetinin aşı yaptırma kararına kesinlikle etkili olduğunu, 35 kişi etkili olduğunu, 11 kişi kararsız olduğunu, 72 kişi etkili olmadığını, 36 kişi de hiç etkili olmadığını belirtmiştir. Katılımcıların büyük çoğunluğu aşı maliyetinin aşı yaptırma kararına engel olmadığını belirtmişlerdir. Ankete katılanlara çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti sorulmuştur. Ankete katılan 170 kişiden 5 ‘i çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyetinin 0-100 TL arası olduğunu, 12 kişi 101-200 TL arası olduğunu, 29 kişi 201-400 TL arası olduğunu, 39 kişi 401-800 TL arası olduğunu, 31 kişi 801-1600TL arası olduğunu, 18 kişi 1601 TL ve üzeri olduğunu 34 kişi bu konuda bilgisinin olmadığını belirtmişlerdir. Katılımcıların çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyetini en yüksek oranda %23.2’si 401-800 TL arası olduğunu, %20.2’si bu konuda bilgisinin olmadığını, %18.5’i 801-1600 TL arası olduğunu, %17.3 ‘ü 201-400 TL arası olduğunu, %10.7’si 1601 TL ve üzeri olduğunu, %7.1’i 101-200 TL arası olduğunu ve % 3’ü 0-100 TL arası olduğunu belirtmişlerdir. Yapılan çalışmada 26-35 yaş arası grup ile birinci basamakta uygulanan aşıların yeterlilik durumu arasında önemli derecede bir ilişki vardır (P<0.05). Katılımcıların eğitim durumu ile Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki fark değerlendirmesi arasında önemli derecede bir ilişki vardır (P<0.05). Katılımcıların meslek grubu ile birinci basamakta uygulanan aşıların yeterli olup olmaması arasında önemli derecede bir ilişki vardır (P<0.05). Katılımcıların meslek grubu ile Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki farkın değerlendirilmesi arasında çok önemli derecede bir ilişki vardır (P<0.05). Katılımcıların meslek grubu ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında bir ilişki vardır (P<0.05). Katılımcıların aşı yaptırdıkları yer ile birinci basamakta aşıların yeterli olması düşüncesi arasında önemli derecede bir ilişki vardır (P<0.05). Ailelerin çocuğunun bağışıklama işlemleriyle olan ilgi derecesi ile 1. Basamakta uygulanan aşıların yeterlilik derecesi arasında çok önemli düzeyde bir ilişki vardır (P<0.05). Birinci basamakta uygulanan aşıların yeterliliği ile aşıların maliyetinin aşı yaptırma kararına etkisi arasında ileri düzeyde bir ilişki vardır (P<0.05). Sağlık Bakanlığı aşı fiyatları ile piyasadaki aşı fiyatları arasındaki farkın değerlendirilmesi ile aşıların maliyetinin aşı yaptırma kararı üzerine etkisi arasında bir ilişki vardır (P<0.05). Aşıların maliyetinin aşı yaptırma kararına etkisi ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında bir ilişki yoktur. Katılımcıların aylık hane geliri ile çocukluk çağı boyunca bir çocuğa yapılan toplam aşılama maliyeti arasında bir ilişki yoktur.

Sonuç olarak, yapılan çalışmalar Sağlık Bakanlığı Aşı alım fiyatları ile piyasada satılan aşıların fiyatları konusunda belirgin fark bulunmaktadır. Bu farkı aileler tahmin etse de rakamsal olarak edinilen bulgular değerlendirildiğinde; ailelerin tahmini sağlık bakanlığı maliyetinin üstünde ancak piyasa fiyatlarının da altında çıkmaktadır. Sonuç olarak koruyucu sağlık hizmetinin başında gelen bağışıklama hizmetinin maliyet analizi yapıldığında piyasa fiyatları ile bakanlık fiyatları arasında belirgin fark mevcut olup; ailelerin bu maliyet konusunda yeterince farkındalığı olmadığı tespit edilmiştir.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

 Kaynaklar

1. Bozkurt G, Erdim L. Güvenli bağışıklamada ebe ve hemşirelerin sorumlulukları. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi 2005;8(3):119-26.

2. Akkaya N. Çocuk ve Erişkinlerde Aşılama.1st Ed.İstanbul:İstanbul Üniversitesi Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi Etkinlikleri; 2010.p.87-93

3. Gürsoy ST, Öcek ZA. Bağışıklamanın ekonomik analizi. İnfeksiyon Dergisi 2007;21(4):217-23.

4. Altun S. 6-14 yaş arası çocuklarda aşılanma oranı ve ailelerin özel aşılarla ilgili bilgi düzeyi. İstanbul: Bakırköy Dr Sadi Konuk Eğitim ve Araştırma Hastanesi; 2008.

5. Ceyhan M. Pediatrik Aşılarda Güncel Yaklaşımlar. ANKEM Dergisi 2013;27(Suppl. 2):S33-7.

6. Özmert EN. Dünya’da ve Türkiye’de aşılama takvimindeki gelişmeler. Çocuk Sağlığı ve Hastalıkları Dergisi 2008;51(3):168-75.

7. Türker N, Örmen B. Suçiçeği aşısı çocukluk dönemi ulusal aşılama programına alınmalı mı? Klinik Gelişim Dergisi 2012;25(1):32-5.

8. Hacımustafaoğlu M. Türkiye’de rutin aşı takvimleri; genişletilmiş aşı takvimi. J Pediatr Inf 2011;5(Suppl. 1):244-51.

9. Özmert Elif N. Dünyada ve Türkiyede Aşılama Takvimindeki Gelişmeler. Çocuk Sağlığı ve Hastalıkları Dergisi 2008;51(3):168-75.

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Zeynep Turk, Ozgur Turk. In Primary Health Care Childhood Immunization Services Costs, Practices. J Clin Anal Med. 2015;6(6):750-754

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Effect of Preoperetive Preparation for Early Extubation and Discharge of Intensive Care Unit

Filiz Alkaya Solmaz 1, Pınar Karabacak 1, Abdurrahman Kara 2, Şenol Gülmen 2, Hüseyin Okutan 2

1 Anesteziyoloji ve Reanimasyon AD, 2 Kalp Damar Cerrahisi AD, Süleyman Demirel Üniversitesi Tıp Fakültesi, Isparta, Türkiye

DOI: 10.4328/JCAM.2388 Received: 06.03.2014 Accepted: 10.04.2014 Published Online: 11.04.2014

Corresponding Author: Filiz Alkaya Solmaz, Süleyman Demirel Üniversitesi, Tıp Fakültesi, Anesteziyoloji ve Reanimasyon AD, Doğu Kampusü, 32200, Isparta, Türkiye. T.: +90 2462112113 GSM: +905327179357 F.: +90 2462371758 E-Mail: filizalkaya@hotmail.com

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Abstract

Aim: In coronary artery bypass surgery patients length of stay in intensive care unit (ICU) has an important role in complication rates and costs. For that reason, the discharging of the patients from the hospital in shorter pe-riod can be provided by taking measures prior to surgical intervention via previously known factors which may affect hospitalization stay. The aim of this study was to determine the role of perioperative risk factors in term of clinical outcomes based on the time of ICU discharge. Material and Method: In this retrospective study, we included 196 patients undergoing coronary artery bypass graft surgery in our clinic. The patients were divided into early (≤2 day) and late (>2 day) ICU discharge groups according to the duration of ICU stay. The preoperative and postoperative risk factors, the complications and the outcomes were evaluated. Results: Age, sex, hyperlipidemia, diabetes mellitus, previous myocardial infarction, renal failure, cerebrovascular acci-dent, hypertension, level of hematocrit and creatinine were not significantly different between the two groups. Patients with hemodynamic instability, respiratory dysfunction, ejection fraction <35%, inotrope administration, left main coronary artery disease, use of intraaortic balloon pump and arrhyth-mia had significantly longer length of stay in ICU (> 2 day) compared to other group (p< 0.05). The shorter duration of intubation time was the most significant factor affecting early discharge according to late discharge group (7.8 ± 3.8 vs 17 ± 9.9 hours, p< 0.001). Discussion: Time of ICU discharge depends on especially to respiratory dysfunction and duration of intubation. Therefore, we assume that modification of preoperative risk factors for re-spiratory may improve clinical outcomes in ICU.

Keywords: Coronary Artery Bypass Surgery; Lenght of Stay; Intensive Care; Surgical

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Giriş

Koroner arter hastalığı (KAH), son yıllarda tüm dünyada olduğu gibi, bizim ülkemizde de mortalitenin ve morbiditenin başlıca nedeni olarak dikkati çekmektedir ve prevalansı giderek artmaktadır. Tetkik ve tedavi yöntemlerinin teknolojik gelişimi nedeniyle, ortalama yaşam süresi uzamış ve tekrarlayan kardiyovasküler olay görülme sıklığı artmıştır [1]. Koroner arter bypass cerrahisi yapılan hasta sayısı buna paralel olarak giderek artmaktadır. Bu artış ile kalp cerrahisi hastalarında maliyet hesaplarının yapılmasına başlanmıştır. Hastalara ayrılacak tıbbi personel, yoğun bakım ve servis yatağı, ekonomik kaynaklar ve benzeri maddi kaynakların cerrahi öncesi planlanması için cerrahi sonrası dönemde gelişebilecek komplikasyonların olasılığının önceden bilinmesi giderek önem kazanmaktadır. Operasyon öncesinde ek hastalıkların dikkatlice değerlendirilip uygun ek tedavilerin verilmesi, anestezi protokollerinin ve miyokardiyal koruma tekniklerinin geliştirilmesi ve postoperatif dönemde yakın takip ile hastaların sorunsuz şekilde taburcu edilmesi sağlanabilmektedir. Yoğun bakımda ve mekanik ventilasyonda uzun süre kalan olgular ekonomik yükü artırmakta ve aynı zamanda yoğun bakım ekipmanlarının başka hastalar tarafından kullanılmasını engellemektedir [2]. Yoğun bakımda ve mekanik ventilasyonda kalış sürelerinin kısaltılması için risk faktörlerinin ortaya konulması ve bu özelliklere sahip hastaların daha yakından izlenerek yoğun tedavilerinin yapılmasının önemi vurgulanmaktadır [3].

Uzamış entübasyon süresi koroner arter bypass greft (KABG) operasyonu sonucunda olguların %5- 22 sinde oluşmaktadır [4-8]. Uzamış entübasyon süresinin sadece hastane maliyetlerini değil, aynı zamanda mortalite ve morbiditeyi de artırdığı gösterilmiştir [9,10]. Anestezi tekniği ve postoperatif yoğun bakım takip ve tedavi yöntemlerinin günümüzde iyileşmesi ile hem entübasyon süresi hem de yoğun bakımda kalış süreleri azalmıştır [10].

Açık kalp cerrahisi uygulanan hastaların ameliyat sonrasında hastanede kalış süresini etkileyen faktörlerin oldukça fazla ve birbirini etkileyen faktörler olmasından dolayı klinik çalışma sonuçları farklılık göstermektedir. Çalışmamızda da yoğun bakımda kalış süresini ve entübasyon süresinin uzamasında etkili olabilecek risk faktörlerini değerlendirdik.

Gereç ve Yöntem

Ocak 2011 – Aralık 2011 tarihleri arasında, ardışık olarak elektif şartlarda izole koroner arter bypass cerrahisi uygulanan 196 hastanın verileri geriye dönük olarak incelendi. Bu süre zarfında cerrahi ve anestezi protokollerinde bir değişiklik yapılmadı. Kronik obstrüktif akciğer hastalığı (KOAH) tanısı öykü, fizik muayene, akciğer grafisi, spirometre, arteriyel kan gazları, intrapulmoner gaz değişim testleri ile koyuldu. EKG’ den aritmi tipi belirlendi ve eşlik eden semptomlar, aritmi ciddiyeti ve kalp pili olan hastalar sorgulandı. İntraaortik balon pompası ( İABP) preoperatif akut sol kalp yetersizliği, kardiyojenik şok, inatçı göğüs ağrısı, papiller kas rüptürü, ventriküler septal defekti ve mitral regurjitasyonda miyokard infarktüsü komplikasyonları olan hastalara preoperatif uygulandı. Böylece miyokardın perfüzyonu arttırıldı ve hemodinaminin stabil hale gelmesi sağlandı. Postoperatif İABP kullanımı ise sol ventrikülde iyileşme sağlanıncaya kadar dolaşımı desteklemek amacıyla uygulandı. Arteriyel greft olarak left internal mammarian arter (LIMA), venöz greft olarak safen venler kullanıldı. LIMA çıkarılan hastalarda sol plevra açılarak, toraks tüpü kondu. Tüm hastalar premedikasyon olarak oral diazepam ve intramüsküler atropin ve midazolam injeksiyonu yapıldıktan sonra operasyon odasına alındı. Anestezi intravenöz fentanil, propofol ve bir kas gevşetici (vekuronyum) ile başlatıldı. Bu ilaçların ekleme dozları ve inhale sevofluran, infüzyon remifentanil ile devam edildi. Cerrahi sonunda tüm hastalar yoğun bakıma alındı. Akciğerlere % 60 oksijen ile zenginleştirilmiş volüm kontrollü ventilasyon yapılırken, tidal volüm 8 mL/kg ayarlandı. Rutin kan gazı analizleri yapılarak PaO2 > 80 mmHg ve PaCO2 35- 45 mmHg olacak şekilde FiO2 ve solunum hızı ayarlandı. Stabil sıcaklık 37 °C ulaşacak şekilde hastalar ısıtıldı ve aşağıdaki kriterleri taşır taşımaz ekstübe edildi: hemodinamik stabilite, aşırı kanama yokluğu (>80 mL/h), normotermi, kan gaz stabilitesi ve ağrı ile şuur kontrolü. Potasyum ve magnezyum eksikliği normal sınırlarda olacak şekilde replase edildi. Ciddi atrial veya ventriküler aritmiler elektriksel veya kimyasal ajanlar kullanılarak derhal düzeltildi. Perioperatif dönemdeki hasta kayıtları geriye dönük olarak değerlendirildi. Hastalar yoğun bakımda kalış sürelerine göre iki gruba ayrıldı. Grup1 (n=75); ameliyat sonrasında yoğun bakımda iki gün ve daha kısa süre kalanlar ve Grup2 (n=121); yoğun bakımda iki günden uzun süre kalanlar olarak belirlendi. Grup 1 ve grup 2’ deki hastaların preoperatif özellikleri Tablo I’ de gösterilmektedir. Tablo II ‘de ise postoperatif özellikleri kayıt edildi. Çok değişkenli regresyon analizine göre yoğun bakımda kalış süresinin uzamasında etkili olan faktörler Tablo III’de gösterildi.

Çalışmanın istatiksel analizleri SPSS 15.0 programı ile yapıldı. (SPSS, Inc., Chicago, III, USA). Veriler ortalama±standart sapma olarak belirtildi. Ameliyat sonrasında hastanede kalış süresini etkileyebilecek olan perioperatif faktörler öncelikle verilerin özelliklerine göre student-t testi ve Mann Whitney U testi kullanılarak değerlendirildi. Tek değişkenli istatistiksel analizler sonucunda yoğun bakımda kalış süresinin uzamasını öngörmede etkili olan veya etkili olabileceği düşünülen risk faktörlerinin çoklu etkileri geriye dönük elemeli çok değişkenli regresyon analizi ile araştırıldı. Her bir risk faktörüne ilişkin odds oranı saptandı. Tüm istatiksel testler iki yönlü idi ve p< 0.05 değeri istatiksel olarak anlamlı kabul edildi.

Bulgular

Tablo I’ de hastaların ameliyat öncesindeki Tablo II’ de ise ameliyat sonrasında kaydedilen hasta verileri gösterilmektedir. Hastaların demografik verileri karşılaştırıldığında gruplar arası fark gözlenmedi. Grup 1 ve grup 2’ deki hastaların operasyon öncesi özellikleri arasında istatiksel olarak anlamlı farklılık gösterenler; Ca kanal blokörü kullanımı, asetil salisilik asit kullanımı, klopidogrel kullanımı, solunum disfonksiyonu, ejeksiyon fraksiyonun < 35 olması, sol ana koroner lezyonun olması olarak belirlendi. Gruplarda LIMA veya safen ven kullanılma oranları ve göğüs tüpünün sayı ve süresinin gruplar arasında fark olmadığı bulundu. Grup 2’deki hastaların preoperatif karakteristik özellikleri açısından asetil salisilik asit kullanımı, kronik pulmoner hastalık varlığı, ejeksiyon fraksiyonun (EF)< 35 olması, sol ana koroner lezyonun olması istatiksel olarak anlamlı farklı bulundu ve bu gruptaki hastaların yoğun bakımda kalış sürelerinin daha uzun olduğu tespit edildi. Yine Grup 2’deki hastaların operasyon sonrası İABP ihtiyacı olması, aritmi olması, inotrop ihtiyacının olması ve entübasyon süresinin uzamasıda yoğun bakımda kalış süresini uzatmış olduğu belirlendi (Tablo III).

Tartışma

Kalp cerrahisi uygulanan hastalarda mortalite ve morbidite açısından hazırlanan birçok risk skorlama sistemi bulunmaktadır. ABD’de kardiyak operasyonlarda Cleveland model, Euroscore, Corrad score ve Parsonnet model gibi araştırmalar bypass cerrahisi sonrası mortalite ve morbiditeyi öngörmede kullanılmaktadır [11- 14]. Bu modellerin hepsinde düşük sol ventrikül (LV) fonksiyonu yüksek puan alarak en önemli risk faktörü olmaktadır. Bizim çalışmamız da, ejeksiyon fraksiyonunun % 35’den az olması diğer deyişle LV fonksiyonlarının düşük olması hem ventilasyon süresinin hem de yoğun bakımda kalış süresinin uzamasına yol açtığını bir kez daha göstermiştir. Cerrahi sonrası mortalite ve morbiditeyle ilişkili bu risk faktörü aynı zamanda uzamış ventilasyon ihtiyacını ve artmış yoğun bakım takip ve tedavisini gerektirmektedir.

Cislaghi ve ark [15] 5123 hasta takipli büyük çalışmada EF< %30 olan hastalarda 2.2 kat daha fazla ventilasyon süresinin uzadığını saptamışlardır. Argenziano ve ark [16] ise 2.4 kat daha fazla oranda düşük EF’lu olguların yoğun bakımda kaldıklarını göstermiştir. Önceki çalışmalarda düşük EF’nuna ek olarak kötü kardiyak fonksiyonlara işaret eden İABP kullanılması, inotrop desteğinin 24 saattten fazla devam etmesi gibi diğer faktörlerde uzamış ventilasyon süresini ve yoğun bakımda kalış süresini tahmin etmede kullanılmıştır. Natarajan ve ark. [17] uzun kardiyopulmoner bypass (KPB) zamanı ve İABP kullanımının uzamış mekanik ventilasyon için önbelirleyici olduğunu bildirmişler ve pompadan çıkmadan önce yerleştirilen İABP’nin KPB süresini uzattığını savunmuşlardır.

Koroner arter bypass cerrahisi uygulanan hastalarda eşlik eden pulmoner ve renal sistem hastalıkları birbirlerini etkileyerek ameliyat sonrasında tabloyu daha da ağırlaştırabilmektedir [18]. Mevcut akciğer fonksiyonları açısından akciğer volüm ve kapasitelerinin değerlendirilmesi gerekmektedir. Eğer volüm ve kapasitelerde azalma söz konusu ise akciğere yönelik tedavi yapıldıktan sonra koroner arter bypass cerrahisine hasta verilmelidir. Çünkü koroner arter bypass cerrahisi akciğer volüm ve kapasitelerinde azalmaya sebep olmaktadır. Bunların normal değerlere dönmesi 4 ay sürmektedir.

KOAH dünyadaki erişkin nüfusun önde gelen mortalite ve morbidite nedenlerinden birisi olup koroner arter bypass cerrahisi uygulanan hastalarda operasyon öncesi ve sonrası başarıyı etkileyen önemli bir problemdir. Koroner arter hastalığına sahip hastalarda KOAH’na oldukça sık rastlanmaktadır. Bu iki hastalığın birlikte görülme oranı % 11- 25,8 olarak belirtilmiştir [19- 20]. KOAH’ ın postoperatif dönemde mortalite ve morbidite üzerine etkilerini karşılaştıran çalışmalarda farklı sonuçlar verilmektedir. Bu iki hastalığın birlikteliği koroner bypass cerrahisinin mortalitesini % 3,7-11,7 artırmaktadır [21]. Gaz alış verişi mekanizmasındaki uzun süreli bozukluk olarak bilinen KOAH hastalarında ilerleyici non-kardiyak dispne ve uzun süreli sigara içme öyküsü varsa operasyon öncesi tedavi edilmeleri gerekmektedir. Bu şekilde oluşabilecek komplikasyonlar minimale indirilebilir. Kalp cerrahisi geçiren hastalarda cerrahi girişim, anestezi uygulaması, median sternotomi ve KPB pulmoner fonksiyonlarda belirgin bir yetersizliğe neden olabilir [22,23]. Buna ek olarak, KOAH gibi önceden var olan pulmoner patolojiler de ameliyat sonrası kardiyopulmoner rezerv üzerine olumsuz etkilere ve hastaların yoğun bakım ve hastanede kalış sürelerinin uzamasına neden olabilir. [22,24]. Bu nedenle koroner arter bypass cerrahisi uygulanacak hastalar için KOAH ciddi bir risk faktörü olarak algılanmalıdır. Çalışmaya dahil edilen hastalarımızın 16’sında KOAH tespit edildi. Yoğun bakımda yatış süresi daha uzun olan hasta grubunda KOAH tanısı alan hastalar belirgin olarak fazlaydı.

Sağlık harcamalarının önemli bir kısmını kapsayan ve sık uygulanan KPB cerrahisinde uzamış mekanik ventilasyon ihtiyacı olacak hastaların tanımlanması ve önleyici stratejilerin belirlenmesi yoğun bakım ve hastanede kalış sürelerini kısaltmak dolayısıyla maliyeti düşürmek açısından oldukça önemlidir. Uzamış mekanik ventilasyon için tanımlanan süre hakkında kesin bir görüş birliği olmamakla birlikte bu süre literatürde 12 saat ile 6 gün arasında değişmektedir [25]. Biz de klinik pratiğimize en uygun sürenin 48 saat olduğunu düşünerek uzamış mekanik ventilasyon süresini 48 saat olarak kabul ettik

Sonuç olarak, mekanik ventilasyon süresinin ve yoğun bakımda kalış süresinin uzayacağı preoperatif dönemde yapılan kapsamlı bir değerlendirme (yaş, mevcut aritmi varlığı, LV fonksiyonları, sol ana koroner hastalığı, solunum disfonksiyonu, inotrop ve intraaortik balon ihtiyaçları) ile öngörülebilir. Yoğun bakımda kalış süresini etkileyen risk faktörlerinin varlığında operasyon zamanlamasının ve uygun tedavi seçeneklerinin değerlendirilerek operasyonun yapılmasının uygun olacağı açıktır. Hastalarda aritmi öyküsü öğrenilmeli, tipi, ciddiyeti, eşlik eden semptomlar sorgulanmalıdır. Kalp hastalığına sıklıkla eşlik eden hipertansiyon, diyabetes mellitus, KOAH, daha önceki hastalık varlığı ve sigara içimi sorgulanmalıdır. Cerrahi öncesi eşlik eden hastalıkların tedavi edilmesi gerekmektedir. Çalışmamızda diğer çalışmalara benzer şekilde bozulmuş LV fonksiyonları, sol ana koroner hastalığı, hemodinamik insitabilite, aritmi varlığı, solunum disfonksiyonu, inotrop ve intraaortik balon uygulaması önemli risk faktörleri olarak ortaya çıkmışlardır.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

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12. Nilsson J, Algotsson L, Hoglund P, Luhrs C, Brandt J. EuroSCORE predicts intensive care unit stay and costs of open heart surgery. Ann Thorac Surg 2004;78(5):1528–34.

13. Geissler HJ, Holzl P, Marohl S, Kuhn-Régnier F, Mehlhorn U, Südkamp M,et al. Risk stratification in heart surgery: comparison of six score systems. Eur J Cardiothorac Surg 2000;17(4):400–6.

14. Nilsson J, Algotsson L, Hoglund P, Luhrs C, Brandt J. Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm. Ann Thorac Surg 2004;77(4):1235–39.

15. Cislaghi F, Condemi AM, Corona A. Predictros of prolonged mechanical ventilation in a cohort of 5123 cardiac surgical patients. Eur J Anesthesiol 2009;26(5):396-403.

16. Argenziano M, Spotnitz HM, Whang W, Bigger JT Jr, Parides M, Rose EA. Risk stratification for coronary bypass surgery in patients with left ventricular dysfunction. Circulation 1999;100(Suppl.2): S119-24.

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18. Akovalı NV, Camkıran A, Zeyneloğlu P, Pirat A, Arslan G. Koroner Arter Baypas Greftleme Cerrahisi Geçiren Erişkinlerde Uzamış Mekanik Ventilasyonun Ön Belirleyicileri. Türk Yoğun Bakım Derneği Dergisi 2013;11(1):6-16.

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20. Angouras DC, Anagnostopoulos CE, Chamogeorgakis TP, Rokkas CK, Swistel DG, Connery CP, et al. Postoperative and long-term outcome of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting. Ann Thorac Surg 2010;89(4):1112–8.

21. Grover FL, Hammermeister KE, Burchfiel C. Initial report of the veterans administration prepoperative risk assesment study for cardiac surgery. Ann Thorac Surg 1990;50(1):12-28.

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24. Türkay C, Akbulut E, Özbudak Ö, Gölbaşı İ, Şahin N, Mete A ve ark. Koroner bypass cerrahisi uygulanan hastalarda kronik obstrüktif akciğer hastalığının mortalite ve morbiditeye etkisi. Türk Göğüs Kalp Damar Cer Derg 2000;8(3): 678- 81.

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How to Cite

Filiz Alkaya Solmaz, Pinar Karabacak, Abdurrahman Kara, Senol Gulmen, Huseyin Okutan. Effect of Preoperetive Preparation for Early Extubation and Discharge of Intensive Care Unit. J Clin Anal Med. 2015;6(6):746-749

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Distribution of Gram Negative Bacteria and Evaluation of Resistance Profiles

Serap Pamukçuoğlu 1, Mehmet Hamdi Pamukçuoğlu 4, Havva Tünay 1, Fadime Arslan 2, Hanife Uzel Taş 3

1 Afyonkarahisar Devlet Hastanesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji, 2 Afyonkarahisar Devlet Hastanesi, Mikrobiyoloji Laboratuvarı, 3 Afyon Kocatepe Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, 4 Afyonkarahisar Devlet Hastanesi, Ortopedi ve Travmatoloji Bölümü, Afyonkarahisar, Türkiye

DOI: 10.4328/JCAM.2415 Received: 19.03.2014 Accepted: 06.04.2014 Published Online: 08.04.2014

Corresponding Author: Serap Pamukçuoğlu, Afyonkarahisar Devlet Hastanesi, Enfeksiyon Hastalıkları ve Klinik Mikrobiyoloji, Afyonkarahisar, Türkiye. GSM: +905056487772 E-Mail: dr.sevim@hotmail.com

Abstract
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Abstract

Aim: In this study, we aimed to examine the distributon of Gram negative bacteria isolated from urine cultures of out-patients in Afyonkarahisar State Hospital and evaluate the antimicrobial resistance rates of these pathogens. Material and Method: Urine samples of out-patients which were sent to mi-crobiology laboratory between 2012-2013 were retrospectively evaluated. The isolates were identified using conventional methods and/or automated Vitec 2.0 system. Antibiogram sensitivities were determined by Kirby-Bauer disc diffusion method or automated system and interpreted on the basis of Clinical and Laboratory Standards Institute (CSI) criteria. Double disc sinergy test (DDST) or Vitec 2.0 system was used to detect extended spectrum beta-lactamase (ESBL).When conventional methods could’t be clarified according to their colony morphologies, gram staining patterns, biochemical test; auto-mated system has been used. Results: A total of 671 isolates acquired from urine samples were studied. 427 Escherichia coli (63.6 %), 165 Klebsiella spp. (24.6 %), 22 Pseudomonas spp. (3.3 %), nine Acinetobacter spp. (1.3 %), 41 Proteus spp. (6.1 %) and seven Serratia (1.0 %) strains were identi-fied among isolates. 97 E.coli (22.8 %) and 41 Klebsiella (24.8 %) isolates were ESBL positive. Most common bacteria were E.coli, 31.1 % of which were resistant to trimethoprim-sulfamethoxazole, 16 % to ciprofloxacin and 3.6 % to nitrofurantoin. Among Enterobacteriaceae, no resistance aganist carbapenems were detected. Moreover, aminoglicoside sensitivity rate was significantly high in this group. Discussion: Microorganisms that have pro-gressively increasing antimicrobial resistance should be considered in the treatment of urinary tract infections. It is also important to use the most appropriate antibiotics to avoid unnecessary usage of these drugs in order to decrease drug resistance rates and ESBL production which may effect the success of the treatment.

Keywords: Antimicrobial Resistance; E.coli ESBL; Urine Cultures; Infection

Full Text

Giriş

Üriner sistem infeksiyonları (ÜSİ) toplumdan kazanılmış infeksiyonlar arasında en sık karşılaşılan bakteriyel infeksiyonlardır. Toplumdan kazanılmış ÜSİ’nda etken mikroorganizma cinsleri ve bunların antibiyotiklere duyarlılıkları farklılıklar gösterebilmektedir. ÜSİ’nın tedavilerinin çok defa ampirik olarak başlanması, etkenlerin antibiyotiklere duyarlılık özelliklerinin bilinmesinin önemini daha da arttırmaktadır [1-3].

Bu çalışmada amacımız hastanemiz polikliniklere başvuran hastalara ait idrar kültürlerinden üreyen Gram negatif etkenlerin dağılımı, antimikrobiyal direnç profillerinin belirlenmesi ve hastanemize ait ÜSİ nedeni patojenlerin cinsleri ve direnç paternleri belirlenerek ampirik tedavinin doğru yönlendirilmesi konusunda klinisyenlere yardımcı olmaktır.

Gereç ve Yöntem

Çalışmamızda 2012-2013 yılları arasında Afyonkarahisar Devlet Hastanesi poliklinik hastalarından mikrobiyoloji laboratuvarına gönderilen 671 idrar örneği retrospektif olarak değerlendirilmiştir. Hastalardan uygun koşullarda alınan orta akım idrar örneklerinin bekletilmeden standart özeyle % 5 koyun kanlı agar ve Eosin Methylene Blue agar besiyerlerine kantitatif ekim yapılmıştır. Besiyerleri 370C’ de 18-24 saat inkübasyonu takiben değerlendirilmiş, tek tip üremesi olan ve koloni sayısı 105 CFU/ml olan kültürler işleme alınmıştır. İdrarın direkt mikroskobik incelemesinde, bir sayım kamarasında > 10 lökosit tespiti piyüri ve santrifüj edilmemiş idrarın gram boyası ile boyanarak immersiyon altında x100 objektifle incelenmesiyle her alanda en az bir bakterinin görünmesi bakteriüri olarak değerlendirilmiştir [4]. Üreyen bakteriler: Konvansiyonel yöntemler (koloni morfolojilerine, gram boyanma özelliklerine, biokimyasal testlerine göre) ile bakteri cins düzeyinde tanımlanamadığında ise otomatik sistem (Vitec 2.0, bioMerieux, Fransa) kullanılmıştır. Antibiyotik duyarlılıkları Kirby-Bauer disk difüzyon yöntemi veya Vitec sistemiyle değerlendirilmiş; Clinical and Laboratory Standards Institute (CLSI) kriterlerine göre yorumlanmıştır [1]. Pratikte ayaktan hastalara en çok kullanılan antibiyotikler çalışmaya dahil edilmiştir. Genişlemiş spektrumlu beta-laktamaz (GSBL) varlığı çift disk sinerji testi (ÇDST) veya otomatik sistem ile araştırılmıştır[1].

Bulgular

Çalışmamıza poliklinik hastalarından 671 izolat dahil edilmiştir. Poliklinik hastalarından izole edilen suşların 427’sinin (% 63.6) Escherichia coli, 165’inin (% 24.6) Klebsiella spp., 22’sinin (% 3.3) Pseudomonas spp., dokuzunun (% 1.3) Acinetobacter spp., 41’inin (% 6.1) Proteus spp., yedisinin (% 1.0) Serratia spp. olduğu saptanmıştır. GSBL pozitifliği E.coli izolatlarının 97’sinde (% 22.8), Klebsiella spp. izolatlarının 41’inde (% 24.8) saptanmıştır. E.coli suşlarının % 31.1’i trimetoprim-sülfametoksazole (TMP-SXT), % 16’sı siprofloksasine, % 3.6’sı nitrofurantoine dirençli olarak bulunmuştur. Enterobactericeae grubu etkenlerde karbapenem grubu antibiyotiklere direnç saptanmazken, aminoglikozid grubu antibiyotiklere duyarlılık oranları yüksek bulunmuştur. Etkenlerin antibiyotik duyarlılıkları Tablo 1’de verildiği gibidir.

Tartışma

Günümüzde ÜSİ bakteriyel infeksiyonlar arasında ilk sıralarda yer alması ve antibiyotiklerin en sık kullanıldığı infeksiyonlar ol¬masından dolayı önemlidir [2]. Toplum kaynaklı ÜSİ etkenleri içerisinde en sık izole edilen etken E.coli’dir [5,6]. Çalışmamızda poliklinik hastalarının idrar kültürlerinden en sık izole edilen et¬ken % 63,6 oranıyla E.coli olmuştur. Ülkemizden bildirilen çeşitli çalışmalarda da E.coli % 43 ile % 80.4 arasında değişen oranlar¬da en fazla karşılaşılan ÜSİ etkeni olduğu belirtilmiştir [2,7-13]. Kanada ve on altı Avrupa ülkesinin ortak verileri olan ECO-SENS 2000 Projesi’nde de % 79.5 oranı ile E.coli en fazla izole edi¬len etken olarak rapor edilmiştir [11]. Çalışmamızda E.coli’yi sı¬rasıyla Klebsiella spp., Enterococcus spp., Proteus spp.takip et¬miştir. Bayraktar ve ark. [3]’nın çalışmasında ayaktan hastalarda sırasıyla E.coli, Klebsiella spp., Enterobacter spp., Proteus spp.; Tolun ve ark.[14]’nın çalışmasında ayaktan hastalarda sırasıyla E.coli, Klebsiella spp., non-fermentatif Gram negatif çomaklar izole edilmiştir. ÜSİ etkeni olarak Enterobacteriaceae ailesi için¬de yer alan gram negatif bakterilerin payı % 70’ten fazladır [15].

Son yıllarda giderek artan antibiyotik direnci ampirik tedavi se¬çeneklerini zorlaştırmaktadır. GSBL üreten bakterilerin neden olduğu en önemli sorun hızla yayılan çoklu antibiyotik direnci ve buna bağlı tedavi başarısızlığıdır. Bu enzimleri kodlayan plaz¬midler beta laktam dışı antibiyotiklere karşı da genetik mater¬yal taşıyabildiği için başta aminoglikozidler olmak üzere kino¬lonlara, tetrasikline, kloramfenikole ve TMP-SXT’e de direnç ge¬liştirmektedir. Uğur ve ark.[16]’nın çalışmasında poliklinik hasta¬larının idrar kültürlerinde üreyen E.coli izolatlarında TMP-SXT’e % 47, siprofloksasine % 35, nitrofurantoine % 10 oranında di¬renç saptanmıştır. Klebsiella spp., bir çok çalışmada ÜSİ’nda E.coli’den sonra ikinci sıklıkta izole edilmekte ve genellikle an¬tibiyotik direnç oranları E.coli’ye göre daha yüksek olarak bil¬dirilmektedi [9]. Güdücüoğlu ve ark.[17] poliklinik izolatlarında E.coli suşlarında GSBL oranını % 29, Klebsiella spp. suşlarında % 49 olarak bildirirken; Albayrak ve ark.[18] sırasıyla % 17.9 ve % 23.7 bulmuştur. Gülcan ve ark. [9]’larının çalışmasında ise bu oran E.coli için % 23.7, Klebsiella spp. için % 29.2 olmuştur. Pul¬lukçu ve ark.[19] poliklinik hastalarının idrar kültürlerinden izo¬le ettikleri E.coli suşlarında GSBL üretimini % 21.4 bulmuşlardır. Çalışmamızda izole edilen E.coli ve Klebsiella spp.’de GSBL ora¬nı sırasıyla % 22.8 ve % 24.8 olarak saptanmıştır.

Ülkemizde toplum kaynaklı ÜSİ düşünülen hastalara genellikle ampirik tedavi uygulanmaktadır. Bu infeksiyonların tedavisin¬de TMP-SXT, siprofloksasin, nitrofurantoin, penisilinler, ikinci ve üçüncü kuşak sefalosporinler sıklıkla kullanılan ilaçlardır [2]. An¬cak bunlara karşı giderek artan oranlarda direnç bildirilmekte¬dir [19,20-24]. TMP-SXT’e o bölgede direnç oranı % 10-20’nin üzerinde ise, ampirik tedavide kullanılması önerilmemektedir [20-24].

Gözüküçük ve ark. [21]’nın yaptığı çalışmada toplum kaynaklı ÜSİ etkeni olarak saptadıkları E.coli izolatlarında TMP-SXT’e % 40, siprofloksasine % 19.8, nitrofurantoine % 12.4 oranında direnç saptanmıştır. 2003-2006 yılları arasında on ülkeden 62 mer¬kezin katıldığı bir çalışmada sistit yakınması olan 4264 hasta¬dan alınan örneklerden 3018’inde üreme olmuş, üreyen bakteri¬lerin % 76.7’sinin E.coli olduğu tespit edilmiş; E.coli’de ampisi¬lin direncinin % 48.3, TMP-SXT direncinin % 29.4, siprofloksasin direncinin % 8.1 olduğu bildirilmiştir [22]. Tolun ve ark.[14]’nın yaptığı bir çalışmada poliklinik hasta gruplarında direnç oranla¬rı E.coli suşları için TMP-SXT’e % 31.2, siprofloksasine % 11.6 saptanmıştır. Doğru ve ark.[23] E. coli suşlarında en fazla siprof¬loksasin (% 45.12), TMP-SXT (% 44.8) ve amoksisilin-klavulanat (% 31.6) direnci gösterirken; meropenem (% 0), imipenem (% 0.2) ve amikasin (% 0.7) en az direnç saptanan antibiyotikler ol¬muşlardır. Ülkemizde yapılan çalışmalarda, toplum kökenli en¬feksiyon etkeni olarak çeşitli klinik örneklerden izole edilen E.coli suşlarında imipenem ve meropeneme karşı direnç saptanmadı¬ğı, buna karşı siprofloksasine karşı direnç oranlarının çok geniş bir aralıkta seyrettiği görülmektedir [8]. Çalışmamızda izole edil¬miş olan E.coli suşlarında TMP-SXT’e % 31.1, siprofloksasine % 16, nitrofurantoine % 3.6 oranında direnç saptanmıştır.

Aminoglikozidler, başta Gram negatif bakterilerle oluşan en¬feksiyonlar olmak üzere birçok enfeksiyonun tedavisinde yay¬gın olarak kullanılmaktadırlar [2,10,23]. Ülkemizde yapılan çe¬şitli çalışmalarda E.coli’lerde amikasin direnci çalışmamızdakine benzer şekilde % 0.3 ile % 5.3 arasında değişen değerlerde bil¬dirilmiştir [23]. Bizim çalışmamızda E.coli’de aminoglikozid gru¬bu antibiyotiklere direnç % 1.4 oranında saptanmıştır. Altopar¬lak ve ark. [24] E.coli’de sefepim direncini % 34.6 olarak bildir¬mişlerdir. Bizim çalışmamızda E.coli’de sefepim direncini % 20.2 olarak tespit ettik. Diğer yandan E.coli’de seftazidim direnci çe¬şitli çalışmalarda % 2 ile % 34 arasında bildirilirken [7,24], ça¬lışmamızda E.coli’de seftazidim direnci % 22.1 oranında bulun¬muştur. E.coli’de nitrofurantoine ait direnç oranı nispeten düşük¬tür. Ülkemizde yapılan değişik çalışmalarda nitrofurantoine ait direnç oranları % 9.3 ile % 14.1 arasında verilmiştir [7,25]. Bizim çalışmamızda nitrofurantoine % 3.6 oranında direnç saptanmış¬tır. Gülcan ve ark.[9]’nın çalışmasında Enterobacteriaceae gru¬bunda en etkili antibiyotikler imipenem ve amikasin, Pseudomo¬nas spp.’de sefepim ve gentamisin; Acinetobacter spp.’de ami¬noglikozid, imipenem ve sefeperazon olarak bildirilmiştir. Ente¬robacteriaceae dışı etkenlerde duyarlılık oranları her merkezde birbirinden farklıdır [9]. Çalışmamızda Enterobacteriaceae gru¬bu etkenlerde karbapenem antibiyotiklere direnç saptamazken, aminoglikozid grubu antibiyotiklerde direnç oranı düşük bulun¬muştur.

Ülkemizin değişik bölgelerinde yapılan çalışmalarda idrar kül¬türlerinde üreyen mikroorganizmalara ait oldukça farklı direnç/ duyarlılık oranları verilmektedir. ÜSİ’nda birinci sırada izole edi¬len üropatojen olan E.coli’nin en önemli direnç mekanizmaların¬dan biri olan GSBL üretimi yalnızca hastane kaynaklı değil, top¬lum kaynaklı suşlarda da artmaktadır [25]. Özellikle Gram nega¬tif bakteri infeksiyonlarında kullanılan antibiyotiklerin bazıları¬na karşı son yıllarda önemli oranlarda direnç gelişmiştir. Bu da tedavi protokollerinin gözden geçirilmesi gereğini doğurmuştur.

Sonuç olarak direnç oranlarının bölgeden bölgeye farklılıklar göstermesi sebebiyle tedavi maliyetlerini azaltmak, doğru te¬daviye başlayabilmek, mortalite ve morbidite gelişme oranlarını azaltabilmek için her bölgenin kendi direnç/duyarlılık oranlarını belirli aralıklarla açıklamasının, doğru tedavi rejimlerine ulaşıla¬bilmesi için gerekli olduğunu düşünmekteyiz. Çalışmamız bölge¬mizin direnç paternini yansıtması açısından önemli olup; hasta-nemizde bu konu ile ilgili olarak yapılan ilk çalışma olmasından dolayı klinisyenler için tedaviyi yönlendirmede yardımcı olabile¬ceğimizi düşünmekteyiz. Çalışmamız ve benzer çalışmaların me¬taanalizleriyle ülkemizin direnç paterni saptanabilir.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

1. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-first Informational Supplement M100-S21. Wayne, PA, USA: CLSI; 2011.

2. Sobel JD, Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Disease. 5th ed. Philadelphia: Churcill Livingstone, 2000:p.773-800.

3. Bayraktar B, Özcan N, Borahan S, Başarı F, Bulut E. Yatan ve ayaktan hastalardan izole edilen üriner sistem infeksiyonu etkeni gram negatif çomaklarda antibiyotiklere direnç, ANKEM Derg 2004;18(3):137-40.

4. Aslan A, Özerdemoğlu RA, Aydoğan FC, Yorgancıgil H, Karakoyun Ö. [Pyuria in hip fracture and coxarthrosis] Gaziantep Tıp Derg 2012;18(2): 66-71.

5. Ağca H. İdrar örneklerinden izole edilen bakteriler ve antibiyotiklere duyarlılıkları, Kocatepe Tıp Derg 2011;12(2):95-100.

6. Demirtürk N, Demirdal T, Eldemir T ve ark. İdrar örneklerinden izole edilen bakterilerin antibiyotiklere duyarlılıkları. Türk Mikrobiyol Cem Derg 2005;35(4):275-8.

7. Ay S, İşeri LA, Duman B. İdrar örneklerinden izole edilen gram olumsuz mikroorganizmaların antibiyotiklere duyarlılıkları. İnönü Üniv. Tıp Fak. Derg 2003;10(2):59-62.

8. Aydos SE, Yavuzdemir Ş, Nohutçu Y, Çavuş İ. Sistit şikayeti ile başvuran hastalardan elde edilen bakterilerin çeşitli antibiyotiklere in vitro duyarlılıkları. J Turk Soc Obstet Gynecol 2006;3(2):118-21.

9. Gülcan A, Aslantürk A, Gülcan E. İdrar kültürlerinden izole edilen mikroorganizmalar ve in vitro antibiyotik duyarlılık durumları. Abant Med J 2012;1(3):129-35.

10. Gündüz T, Mumcuoğlu İ. İdrar örneklerinden izole edilen Escherichia coli suşlarının antibiyotiklere duyarlılıkları. Türk Mikrobiyoloji Cem Derg 2004;34(3):157-61.

11. Kahlmeter G, Poulsen HO. Antimicrobial susceptibility of Escherichia coli from community-acquired urinary tract infection in Europe: the ECO.SENS study revisited. Int J Antimicrob Agents 2012;39(1):45-51.

12. Kahlmeter G. The ECO-SENS Project: a prospective, multinational, multicenter epidemiological survey of the prevalence and antimicrobial suspectibility of urinary tract pathogens-interim report. J Antimicrob Chemother 2000;46(Suppl 1):15-22.

13. Küçükbayrak A, Behçet M, Güler S, Özdemir D. Üriner semptomu olan poliklinik hastalarının idrarında üreyen E. coli suşlarının antibiyotik duyarlılığı. Tıp Araştırmaları Derg 2006;4(1):18-21.

14. Tolun V, Akbulut DT, Çatal Ç, Turan N, Anğ-Küçüker M, Anğ Ö. Yatan ve ayaktan hastalardan izole edilen üriner sistem infeksiyonu etkeni gram negatif çomakların antibiyotiklere duyarlılıkları. Türk Mikrobiyol Cem Derg 2002;32(1-2):69-74.

15. Alım A, Oğuzkaya-Artan M. İdrar örneklerinden izole edilen gram negatif bakteriler ve antibiyotik duyarlılıkları. Türk Mikrobiyol Cem Derg 2008;38(3-4):122-5.

16. Uğur AR, Türkdağı H, Tuncer İ, Fındık D, Arslan U. İdrar kültürlerinden izole edilen Escherichia coli suşlarının antibiyotik duyarlılığı ve genişlemiş spektrumlu beta-laktamaz oranı. ANKEM Derg 2013;27(1):13-8.

17. Güdücüoğlu H, Baykal S, İzci H ve ark. Genişlemiş spektrumlu beta-laktamaz (GSBL) Escherichia coli ve Klebsiella pneumoniae suşlarının antibiyotiklere direnci. ANKEM Derg 2007;21(3):155-60.

18. Albayrak N, Kaya Ş. Çeşitli klinik örneklerden izole edilen Escherichia coli ve Klebsiella pneumoniae suşlarının genişlemiş spektrumlu beta laktamaz üretimleri ve antibiyotik direnç oranları. Türk Mikrobiyol Cem Derg 2009;39(1-2):16-21.

19. Pullukçu H, Aydemir Ş, Taşbakan MI ve ark. Nitrofurantoinin idrar kültürlerinden soyutlanan Escherichia colisuşlarına in vitro etkinliği. İnfeksiyon Derg 2007;2(4)1:197-200.

20. Raz R, Chazan B, Kennes Y, Colodner R, Rottensterich E, Dan M et al. Empiric use of trimethoprim-sulfamethoxazole (TMP-SMX) in the treatment of women with uncomplicated urinary tract infections, in a geographical area with a high prevalence of TMP-SMX-resistant uropathogens. Clin Infect Dis 2002;34(9):1165-9.

21. Gözüküçük R, Çakıroğlu B, Nas Y. Toplum kaynaklı üriner sistem enfeksiyonu etkeni olarak saptanan Escherichia coli izolatlarının antibiyotik duyarlılıkları. JAREM 2012;2(3):101-3.

22. De Cueto M, Lopez L, Hernandez JR et al. In vitro activity of fosfomycin against extended-spectrum-beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae: comparision of susceptibility testing procedures. Antimicrob Agents Chemother 2006;50(1):368-70.

23. Doğru A, Karatoka B, Ergen P, Aydın Ö, Tigen E. İdrar yolu enfeksiyonlarında direnç oranları: 2010 yılı verilerimiz. Turkish J Urology 2013;39(4):237-43.

24. Altoparlak A, Özbek A, Aktaş F. Üriner sistem infeksiyonlarından izole edilen bakterilerin çeşitli antibiyotiklere duyarlılıkları. Türk Mikrobiyol Cem Derg 2002;32(3-4):167-73

25. Çitil B, Çöplü N, Gözalan A, Öncül Ö, Karaca Y, Esen B. Üriner sistem infeksiyonu etkeni olan Enterobacteriaceae türlerinin iki yıllık antibiyotik direnç oranları değerlendirilmesi. Kocatepe Tıp Derg 2006;6(1):31-5.

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How to Cite

Serap Pamukcuoglu, Mehmet Hamdi Pamukcuoglu, Havva Tunay, Fadime Arslan, Hanife Uzel Tas. Distribution of Gram Negative Bacteria and Evaluation of Resistance Profiles. J Clin Anal Med. 2015;6(6):742-745

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The Effects of Surgical Treatment on Elbow and Hand Functions in Gartland Type 3 Children’s Humerus Supracondylar Fractures with Posterior Approach

Fırat Seyfettinoğlu 1, Fatih Duygun 2, Ömer Çetin 3, Hakan Çiçek 1, Hasan Ulaş Oğur 1, Osman Çiloğlu 1

1 Ortopedi ve Travmatoloji Kliniği, Adana Numune Eğitim ve Araştırma Hastanesi, Adana, 2 Ortopedi ve Travmatoloji Kliniği, Antalya Eğitim ve Araştırma Hastanesi, Antalya, 3 Ortopedi ve Travmatoloji Kliniği, İzmir Atatürk Eğitim ve Araştırma Hastanesi, İzmir, Türkiye

DOI: 10.4328/JCAM.2383 Received: 06.03.2014 Accepted: 28.03.2014 Published Online: 08.04.2013

Corresponding Author: Fırat Seyfettinoğlu, Adana Numune Eğitim ve Araştırma Hastanesi, 4. Kat, Ortopedi ve Tarvmatoloji Kliniği, Yüreğir, Adana, Türkiye. T.: +90 3223550101/4427 F.: +90 3223550301 E-Mail:firatseyf@yahoo.com

Abstract
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Abstract

Aim: The aim of this study was to evaluate the effects of treatment with open surgery methods on elbow and hand functions in paediatric patients with a Gartland Type 3 humerus supracondylar fracture. Material and Method: The study comprised 25 patients (7 female, 18 male; mean age 6.7 years, range, 3-13 years) who were treated and regularly followed up at our clinic between 2005 and 2009. All the fractures were extension Type 3 according to the Gartland classification. All the patients were treated with posterior approach open reduction and internal fixation. 20 patients underwent surgery within the first 8 hours and 5 patients between 8-72 hours (mean 57.6 hours). In the postoperative follow-up, carrying angle, elbow range of movement, grip strength and pinch strength were measured with hand evaluation tests. Upper extremity functions were scored with the Q-DASH scoring system. The functional and cosmetic results were evaluated according to the Flynn criteria. Results: According to the Flynn criteria, 20 of the 25 patients had excellent results, 1 good, 3 fair and 1 poor. At the final follow-up examina-tion, 6 patients (24%) had limited flexion of mean 3.9° (min 5°, max 25°). No restriction of extension was seen in any patient. While there was a loss of grip strength of mean 0.9kg (4%) compared with the healthy side, the loss of pinch strength was mean 0.05 kg (0.8%). Compared with the healthy side, 16 patients had a loss of carrying angle of mean 2.1° (min -10°, max+5°). Of these, the loss was valgus in 3 patients (mean 3.6°,min+3°–max+5° ), and varus in 12 (mean 5.7°, min -10° – max -3°). In 10 patients no loss of carrying angle was determined. Discussion: Limited extension and triceps insufficiency which are the most significant disadvantages of the posterior approach were seen to have completely recovered at the final follow-up. Loss of carrying angle which develops following treatment of paediatric humerus supracondylar fractures did not affect the functional results to a significant degree.

Keywords: Child; Supracondylar Humeral Fracture; Posterior Approach

Full Text

Giriş

Suprakondiler humerus kırıkları çocuk ve adölesan çağda çok sık görülen ve acil serviste sıklıkla karşılaşılan dirsek çevresi kırıklarındandır. Bu yaş grubundaki dirsek çevresi kırıklarının % 50-70 ini oluşturur [1-3]. Bu kırıkların büyük çoğunluğu ekstansiyon tipidir ve Gartland’a göre 3 tipe ayrılır. Tip 1; yer değiştirmemiş kırıklar, tip 2 ; yer değiştirmiş fakat posterior korteksin sağlam olduğu kırıklar, tip 3 ise yer değiştirmiş kırıklardır [4-6]. Uygulanan tedavi yöntemleri kırığın tipine göre farklı sonuçlar verir. Bu kırıkların tedavisinde traksiyon, kapalı redüksiyon ve alçılama, perkütan çivileme ve alçılama, açık redüksiyon ve internal tespit gibi seçenekler bulunmaktadır.

Kapalı cerrahi girişimler (kapalı redüksiyon+perkütan çivileme), tip 2 ve 3 kırıklarda kullanımı giderek artan ve günümüzde altın standart olarak kabul edilen tedavi yöntemi olagelmiştir [3-7]. Ancak kapalı redüksiyonun başarılı olamadığı durumlarda ise açık redüksiyon ve internal tespit uygulanmaktadır [8]. Ayrıca perkütan çivileme tekniğinde gelişebilen nörovasküler komplikasyonlar ve alınan radyasyon dozu tekniğin dezavantajlarıdır [9].

Açık cerrahi girişimler ise medial,lateral,anterior veya posterior yolla gerçekleştirilebilir. Her bir yaklaşımın kendine göre avantaj ve dezavantajları mevcuttur [10-12].

Bu çalışmada triseps kesilmeden posterior yaklaşım ile tedavi edilen Gartland tip 3 çocuk humerus suprakondiler kırığı olan hastalarda; cerrahi tedavinin fonksiyonel ve kozmetik sonuçlarının yanı sıra dirsek ve el fonksiyonları üzerindeki etkilerinin değerlendirilmesi amaçlandı.

Gereç ve Yöntem

Aralık 2005- Ocak 2009 tarihleri arasında kliniğimizde suprakondiler humerus kırığı nedeniyle cerrahi olarak tedavi edilmiş ve düzenli takibi yapılabilen 25 hasta (7 K/18 E; ortalama yaş:6,7 dağılım:3-13) bu çalışmaya dahil edildi. Aynı ekstremitede başka kırığı olan hastalar,daha önce suprakondiler humerus kırığı geçirmiş hastalar ve karşı ekstremitesinde herhangi bir kırığı olan hastalar çalışmaya alınmadı. Hastalardan 16’sının (%64) sol, 9’unun (%36) sağ dirseği kırıktı. Hastaların 17 sinin (%68) dominant olmayan ekstremitesi kırıktı. Hastaların 18’sinde (%72) kırığın sebebi yüksekten düşmeydi (2 metreden az; yatak, sandalye gibi). Diğer hastalar ise merdivenden düşme, bisikletten düşme, trafik kazası gibi sebeplerle acil servise başvurmuşlardı. Çalışmaya dahil bütün hastalarda kırıklar ekstansiyon tipinde olup kırıklar Gartland’a göre sınıflandırıldı [2]. Bütün hastalarda tip 3 kırık mevcutu.

Bütün hastalara posterior girişimle triseps kesilmeden açık redüksiyon ve 2 adet çapraz k teli ile fiksasyon (ARİF) yapıldı. Ulnar sinir bulunarak korumaya alındı. Ulnar olukta gevşetme yapıldı. Triseps kasının medial ve lateral kenarlarından, kası kesmeden humerusun posterior distal bölgesine ulaşıldı.

Ameliyat sonrası hastalara dirsek 90° ve önkol nötral pozisyonda olacak şekilde uzun kol alçı atel uygulandı. Ameliyat sonrası 15 günde dikişler alındı. Kaynama bulgularına bağlı olarak 4-5.haftada poliklinik şartlarında k telleri çekildi. Ameliyat sonrası 6.haftada atel çıkarılıp pasif-aktif egzersizlere başlandı.

Yirmi hasta (%80) ilk 8 saat içinde,kalan 5 hasta (%20) ise 8-72. saatler arasında ameliyat edildi.

Hastaların yaşa ve cinse göre demografik dağılımı, kırık tipi, yapılan cerrahi işlem ve ameliyat zamanları tablo 1 de verilmiştir.

Hastaların son kontrolde;taşıma açıları,dirsek fonksiyonları,el fonksiyonları,iki nokta ayrımı,el kavrama gücü ve el çimdikleme gücü;el dinamometresi ve pinchmetresi (Baseline Hydraulic Hand Dynamometer; White Plains, NY,ABD) ile değerlendirildi. Ölçümler standart bir pozisyonda ; hasta oturur durumda omuz adduksiyon ve nötral rotasyonda, dirsek 90˚ fleksiyonda,önkol nötral pozisyonda, el bileği 0-30˚ ekstansiyonda ve 0-15˚ ulnar deviasyondayken yapıldı. Q-DASH skorlama sistemi ile üst ekstremite fonksiyonları puanlandı [13]. Q-DASH puanlama sistemi üst ekstremite ile ilgili (omuz ,dirsek,el-el bileği) rahatsızlıklarda etkilenmiş ekstremitedeki bazı fonksiyonlar için puanlar vererek objektif bir değerlendirme yapılmasını amaçlar. Puanın fazla olması sakatlığın çok olduğu anlamına gelir. Ayrıca hastalar Flynn [14] ölçütlerine göre fonksiyonel ve kozmetik açıdan değerlendirildi. Kozmetik sonuçların değerlendirilmesi taşıma açısının goniometre ile karşı tarafla kıyaslanarak ölçülmesi ile yapıldı. Klinik değerlendirmeler ve radyografik ölçümler tek gözlemci tarafından yapıldı. Ortalama takip süresi 32 ay idi (dağılım:24-43 ay). Sonuçlar SPSS 15.0 programına yüklendi. Parametreler chi-square istatistiksel analiz metodu ile değerlendirildi.

Sonuçlar

Hastaların hastanede yatış süresi ortalama 3,3 gündü (2-7 gün). Hastaların Flynn kriterlerine göre fonksiyonel ve kozmetik sonuçları tablo 2 de gösterilmiştir .(Resim1a,b,c)

Hastalarda ameliyat sonrası sinir arazı, kompartman sendromu, çivi dibi enfeksiyonu, volkmann iskemik kontraktürü gibi komplikasyonlarla karşılaşılmadı. Bir hastada ameliyat öncesi radial sinir arazı,1 hastada ameliyat öncesi ulnar sinir arazı mevcuttu. Hastaların 2.yıl kontrollerinde sinir arazlarının tümüyle düzeldiği izlendi.

Son kontrolde 6 hastada (%24) ortalama 3.9° (min 5° – max 25°) fleksiyon kısıtlılığı mevcuttu. Hastaların hiçbirinde son kontrol muayenelerinde ekstansiyon kısıtlılığı görülmedi.

Sağlam dirsekle kıyaslama sonrası 16 (%60) hastada ortalama 2.1º(min -10° – max +5°) taşıma açısı kaybı mevcuttu.Bunlardan 3 tanesi valgus yönünde (ort 3.6°,min+3°–max+5° ),12 tanesi varus yönünde ort 5.7°, (min -10° – max -3°) kayıp mevcut iken 10 (%40) hastada taşıma açısı kaybına rastlanmadı. Taşıma açısı kaybı olan ve olmayan hastalar kendi aralarında karşılaştırıldığında fonksiyonel sonuçlarda anlamlı fark olmadığı görüldü. (p>0.05).

Hastaların fleksiyon dereceleri ve taşıma açıları tablo 3 de gösterilmiştir.

Hastalar Q-DASH skorlaması ile değerlendirildiğinde 23 hastanın günlük aktivitelerinde hiçbir sorun yaşamadığı (Q-DASH:250p), 2 hastanın ise birtakım aktivitelerde sorun yaşadığı (Q-DASH:425 ve 475p) görüldü. Bu 2 hasta incelendiğinde ikisinin ortalama 17,5°(25° ve 10°) fleksiyon kısıtlılığının olduğu ve ikisinin de dominant ekstremitede kırık olduğu gözlendi.

Hastaların iki eldeki otonom duyu bölgeleri değerlendirildiğinde iki nokta ayrımı açısından fark saptanmadı. İlk 8 saat içinde ameliyat edilenlerle daha geç ameliyat edilenler arasında fonksiyonel açıdan fark saptanmadı. (p>0.05).

Sağlam tarafla kıyaslama sonrası elde ortalama 0.9 kg (%4) kavrama gücü kaybı mevcutken, ortalama 0,05 kg (%0.8) çimdikleme gücü kaybı mevcut idi.Hastaların dominant-nondominant ekstremite ayrımını göz ardı ederek yapılan istatistiksel değerlendirme sonucu hastalarda elde kavrama gücü kaybı açısından istatistiksel anlamlı fark olmadığı görüldü (p>0.05). Hastaların elde kas gücü ve çimdikleme gücü değerleri tablo 4 te verilmiştir.

Tartışma

Suprakondiler humerus kırıklarının tedavisinde ana amaç; fonksiyonel ve kozmetik açıdan kabul edilebilir;hareket kısıtlılığı olmayan bir üst ekstremite sağlamaktır.Çoğu araştırmacıya göre ideal tedavi kapalı redüksiyon perkütan çivileme (KRPÇ) [9,11,15] iken bazı serilerde açık redüksiyon ve internal fiksasyonun (ARİF) daha iyi sonuçlar verdiği savunulmaktadır [16,17]. Özellikler tip 3 kırıklarda kapalı anatomik redüksiyon başarılmasının zorluğu ve alınan yüksek radyasyon dozu gibi dezavantajlarından dolayı direk açık redüksiyonda önerilmektedir [17]. Bizim çalışmamızdaki hastaların hepsi tip 3 kırık olduğundan ve tam anatomik redüksiyon hedeflendiğinden açık redüksiyon ile tedavi edildiler.

Çocuk suprakondiler humerus kırıklarının açık redüksiyonunda birçok cerrahi yaklaşım (medial, lateral, anterior, posterior, kombine) tarif edilmiştir [18-21] her yaklaşımın kendine göre avantaj ve dezavantajları bildirilmiştir. Ay [10] ve Ersan [18] anterior girişimin güvenli ve efektif olduğunu bildirmiştir. Bamrungthin [20] posterior ve lateral yaklaşımları karşılaştırdıkları çalışmasında posterior girişimin daha kısa sürdüğünü ancak fonksiyonel sonuçlar açısından anlamlı fark olmadığını bildirmiştir. Eren ve ark.[19] medial ve lateral girişimi karşılaştırdıkları çalışmalarına her iki tekniğin sonuçları arasında anlamlı fark olmadığını ancak medial girişimin daha estetik ve ulnar sinir hasarının daha az olduğunu bildirmişlerdir. Posterior girişimin en büyük dezavantajı triseps kasının zedelenmesi ve eklemde hareket kaybı olarak görülmektedir. Ancak Ekşioğlu [21] ve Sibly [22] yaptıkları çalışmada posterior yaklaşımın uzun dönemde eklem hareket kaybına neden olmadığını bildirmişlerdir. Ülkemizden Bombacı ve arkadaşlarının [12] posterior ve lateral insizyonlu olgularının karşılaştırmasında, lateral yaklaşım uygulanan olgularda humerus alt ucunun anteriorda tam olarak ortaya konulamaması sonucu medial kortekste yeterli redüksiyon ve tutunmanın sağlanamadığını vurgulanmıştır. Bu nedenle posterior yaklaşımın daha avantajlı olduğunu savunmuştur. Bizim çalışmamız da da uzun dönem takipte triseps kasında zayıflık veya dirsekte hareket kısıtlılığı kalmadığı görülmüştür.

Literatürde bu kırıklara sinir hasarı eşlik etme oranı % 12-20 [20-22] ve genellikle nöropraksi şeklindedir. Bu çalışmada da 2 hastada (%10,5) ameliyat öncesi sinir hasarı saptandı. Her iki hastanın da son takibinde tam düzelme mevcuttu.

Çocuk suprakondiler humerus kırıklarının cerrahi tedavisinin zamanlaması güncel literatürde tartışılan konulardan biridir. Son çalışmalar eğer açık kırık, dolaşım problemi, kompartman sendromu gibi mutlak acil cerrahi endikasyon yoksa gecikmiş ameliyat yapılabileceğini desteklemektedir [23-26]. Akmaz ve arkadaşları yaptıkları çalışmada ilk 8 saatte ameliyat ettikleri hastalarla 8 saatten sonra ameliyat ettikleri hastaları karşılaştırmışlar; her iki grupta da tatminkar sonuç aldıklarını bildirmişlerdir [23]. Bizim çalışmamızda da 20 hasta ilk 8 saat içinde,5 hasta ise ortalama 52.saatte (9-72. saat) ameliyat edildi.Erken veya gecikmiş ameliyat edilen hastalarda da kozmetik ve fonksiyonel açıdan anlamlı fark olmadığı görüldü.

Flynn ve ark. kapalı redüksiyon ve perkütan çivileme ile ameliyat edilen 52 olgunun %18’inde vasküler, %13’ünde nöronal komplikasyon bildirmişlerdir [10]. Yine bazı kaynaklarda perkütan çivileme sonrasında oluşan sinir yaralanmalarının oranı %7 ile %16 arasında bildirilmiştir [27,28]. Bizim çalışmamızda ise vasküler ve nöral komplikasyona rastlanmadı.

Birçok yayında Suprakondiler humerus kırıkarının cerrahi tedavisinden sonra takip kriteri olarak Flynn ölçütleri kullanılmıştır [18,19,28,29,30]. Flynn ölçütlerine göre birçok araştırıcı %85-90 oranında fonksiyonel açıdan mükemmel–iyi sonuç bildirmiştir [10,18,19,21,25]. Bizim çalışmamızda da hastaların tümü Flynn ölçütlerine göre değerlendirildiğinde %84 mükemmel-iyi sonuç elde edildi. Bir hastada kötü sonuç alındı.Bu hastada kırık dominant taraftaydı ve 25 derecelik fleksiyon kısıtlılığı ile iyileşmişti. Flynn ölçütleri daha çok subjektif kriterler olup fonksiyonel ve kozmetik sonuçlar hakkında fikir verir.

Bu çalışmada Flynn ölçütlerinin yanı sıra hastaların dinamometre ve pinchmetre ile kırık taraftaki el fonksiyonlarını objektif olarak değerlendirilmeye çalışıldı.Buna göre son kontrolde elde kavrama gücünde ortalama %4.2,çimdikleme gücünde %4 kayıp mevcuttu. Ayrıca Q-DASH puanlama sistemi ile kırık taraf üst ekstremite fonksiyonları puanlandı. Fleksiyon kısıtlılığı olan Gartland tip 3 kırıklı 2 hastanın Q-DASH skorunun yüksek olduğu görüldü.

Sonuç olarak,literatürde posterior girişimin en önemli dezavantajı ekstansiyon kısıtlılığı triceps yetmezliği olarak bildirilmişsede biz 25 hastalık serimizde son kontrolde fonksiyonel sonuçları etkileyecek kadar ekstansiyon kısıtlılığı görmedik. Suprakondiler humerus kırıklı hastalarda cerrahi tedavi sonrası fonksiyonel sonuçlar iyi olsada el kavrama ve çimdikleme gücü etkilenebilmektedir. Hastaların ameliyat öncesi dinamometre ve pinchmetre ile el fonksiyonlarının ölçülememiş olması ve vaka sayınsın az olması çalışmayı kısıtlayan öğeler olsada çocuk suprakondiler humerus kırıklarının ameliyat sonrası takibinde el fonksiyonlarının da etkilenebileceği unutulmamalıdır. El fonksiyonlarındaki azalma için daha geniş hasta sayılı prospektif randomize çalışmalara ihtiyaç vardır.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

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5.Lee YH, Lee SK, Kim BS, Chung MS, Baek GH, Gong HS, et al. Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children. J Pediatr Orthop 2008;28:417-22

6. Aksakal M, Ermutlu C, Sarısozen B, Akesen B.Çocuklarda nörovasküler yaralanmalı suprakondiler humerus kırıklarına yaklaşım. Acta Orthop Traumatol Turc 2013;47(4):244-9.

7. Ababneh M, Shannak A, Agabi S, Hadidi S. The treatment of displaced supracondylar fractures of the humerus in children. A comparison of three methods. Int Orthop 1998; 22:263-5

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11.Flynn JC, Matthews JG, Benoit RL. Blind pinning of displaced supracondylar fractures of the humerus in children. Sixteen years’ experience with long-term follow-up J Bone Joint Surg Am 1974;56:263-72.

12.Bombacı H, Gereli A, Küçükyazıcı Ö, Görgeç M, Deniz G. Suprakondiler humerus kırıklarında cerrahi yaklaşımın sonuca etkisi. Ulusal Travma Acil Cerrahi Derg 2007;13:49-54.

13. Gummesson C, Ward MM, Atroski I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick-DASH) : validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44.

14. Flynn JM, Sarwark JF, Waters PM, Bae DS, Lemke LP. The operative management of pediatric fractures of the upper extremity. J Bone Joint Surg Am 2002;84:2078–89.

15. Pirone AM, Graham HK, Krajhich JI. Management of displaced extension-type supracondylar fractures of the humerus in children. J Bone Joint Surg Am 1988;70:641-50.

16.Cramer KE, Devito DP, Green NE. Comparison of closed reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1992;6:407-12.

17.Kotwal PP, Mani GV, Dave PK. Open reduction and internal fixation of displaced supracondylar fractures of the humerus. Int Surg 1989;74:119–22.

18.Ersan Ö,Gönen E,Arık A,Daşar U,Ateş Y. Treatment of supracondylar fractures of the humerus in children through an anterior approach is a safe and effective method. International Orthopaedics (SICOT) 2009;33:1371–5.

19.Eren A,Özkut T,Altıntaş F,Güven M. Çocuklarda suprakondiler humerus tip 3 kırıkların tedavisinde lateral ve medial girişimler ile cerrahi tedavi sonuçlarının fonksiyonel ve kozmetik açıdan karşılaştırlması. Acta Orthop Traumatol Turc 2005;39(3):199-204.

20.Bamrungthin N. Comparison of posterior and lateral surgical approach in management of type 3 supracondylar fractures of the humerus among the children. J Med Assoc Thai 2008;91(4):502-6.

21.Ekşioğlu F,Güdemez E,Sepici B.Çocuk suprakondiler deplase humerus kırıklarında açık redüksiyon internal fiksasyon yöntemi ile kapalı redüksiyon perkütan çivileme yönteminin karşılaştrılması. Eklem Hastalıkları Cerrahisi 2000;11(2):173-8.

22.Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood. Range of movement following posterior approach to open reduction. Injury 1991; 22:456-8.

23.Akmaz İ,Arpacıoğlu Ö,Pehlivan Ö,Solakoğlu C,Kıral A.Çocuk deplase suprakondiler humerus kırıklarında ameliyat zamanlamasının klinik ve radyolojik sonuçlarımız üzerine etkisi. Eklem Hastalıkları Cerrahisi 2004;15(3):135-42.

24.Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH. The effect of surgical timing on the perioperative complications of treatment of supracondylar humeral fractures in children. J Bone Joint Surg 2001; 83(3):323-7.

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26.Dikmen B,Duman İG,Özden R,Uruç V,Doğramacı Y,Kalacı A.Çocuklarda suprakondiler humerus kırıklarında cerrahi tedavi sonuçlarımız. Dicle Tıp Derg 2014;41(1):199-204

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How to Cite

Firat Seyfettinoglu, Fatih Duygun, Omer Cetin, Hakan Cicek, Hasan Ulas Ogur, Osman Ciloglu. The Effects of Surgical Treatment on Elbow and Hand Functions in Gartland Type 3 Children s Humerus. J Clin Anal Med. 2015;6(6):737-741

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The Relationship of Histologically Diagnosed Chronic Prostatic Inflammation and Lower Urinary Tract Symptoms

Sebahattin Albayrak, Kürşad Zengin, Serhat Tanık, Hasan Bakırtaş, Muhammed Abdurrahim İmamoğlu, Mesut Gürdal

Bozok Üniversitesi Tıp Fakültesi, Üroloji Ana Bilim Dalı, Yozgat, Türkiye

DOI: 10.4328/JCAM.2397 Received: 11.03.2014 Accepted: 02.04.2014 Published Online: 03.04.2014

Corresponding Author: Sebahattin Albayrak, Bozok Üniversitesi Tıp Fakültesi Eğitim ve Uygulama Hastanesi, Üroloji Ana Bilim Dalı, 66000, Yozgat, Türkiye. GSM: +905055186771 F.: +90 3542140612 E-Mail: salbayrak77@hotmail.com

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Abstract

Aim: To evaluate the relationship between pre-biopsy PSA levels, Internation-al Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), pros-tate volume and positive core numbers of histologically proved chronic pros-tatitis in the patients whom underwent transrectal ultrasound guided biopsy for elevated prostate specific antigen (PSA) levels. Material and Method: Be-tween January 2012 and 2014, 152 patients underwent TRUS biopsy. Their medical records are examined retrospectively. The mean age of the patients were 62 (45-75). The pathologic specimens were evaluated for the number of cores with chronic prostatitis and percentage of prostatitis. Pre-biopsy levels of PSA, IPSS, maximum urinary flow rate, prostate volume are compared with the number positive cores for chronic prostatitis and their percentages. These variables also compared in the non-chronic prostatitis patients. Re-sults: There was no statistically significant correlation between the positive number of cores for chronic prostatitis and age (P=0.5, r=0.055), a positive correlation was observed between IPSS (P<0.001, r=0.646), prostate volume (P=0.04, r=0.185), and PSA (P=0.001, r=0,309). There was a statistically negative correlation observed with maximum urinary flow rate (P<0.001, r= -0,628). Discussion: The higher values of IPSS values in chronic prostatitis patients, and lower values of maximum urinary flow rates demonstrated that chronic prostatitis is correlated with lower urinary tract symptoms. Similarly, statistically significant higher PSA levels observed in the chronic prostatitis patients demonstrated the relation of inflammation and PSA like the previ-ous studies in the literature.

Keywords: Chronic Prostatitis; Lower Urinary Tract Symptoms; Prostate Biopsy

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Giriş

Prostatitler patolojik tanım olarak prostat bezinin enflamasyonu olarak bilinse de üriner sistem semptomları, enflamasyon, prostat kaynaklı ağrı ve etiyopatogenezi tam olarak anlaşılamayan bir klinik tabloyu ifade etmek için kullanılmaktadır [1-3]. Kronik enflamatuvar prostat hastalıklarının enfeksiyöz olmayan nedenli olanlar bakteriyel prostatite göre sekiz kat daha sık görülürler. Bu nedenle bu hastalıkların kökeninde oto-immün bir cevap olma olasılığı daha yüksektir. Burada tam olarak açığa çıkarılamamış olan, bu immün reaksiyonun nasıl başladığıdır. Bu reaksiyon yabancı antijenler tarafından veya oto antijenler tarafından ya da her ikisi tarafından başlatılıyor olabilir. Her şartta prostatik enflamasyonun en azından hormonal etkiler, genetik yapı ve ilerleyen yaş ile ilişkili olduğu söylenebilir [4]. Benign prostat hiperplazisinde (BPH) kronik enflamasyon oluşumunu açıklamak üzere iki hipotez ortaya konulmuştur. Bunlardan birincisi enfeksiyon ve neden olduğu olaylardır. Diğeri ise oto-immun bir cevaptır. Bakteri veya virüslerin BPH doku örneklerinde çok sık saptanması ve kronik prostatitde bu enfeksiyon etkenlerinin birlikte görülebilmesi, enfeksiyon hipotezi için destek oluşturmaktadır. Sauver ve arkadaşlarının çalışmasında bazı BPH hastalarının geçmişinde bir prostatit öyküsünün mevcudiyeti, BPH oluşmasında prostatitin bir risk faktörü olabileceğini göstermektedir [5]. Mevcut klinik veriler BPH hastalarında kronik prostatik enflamasyonun yaygın olduğunu göstermiştir. Yapılan bir subanalizde prostat biyopsilerinin %77’sinde kronik prostatik enflamasyon tespit edilebileceği belirlenmiştir [6].

Benign prostat hiperplazisinde kişilerin yaşam kaliteleri bozulmaktadır [7]. Benign prostat hiperplazisi, hastaların yaşam kalitelerini bozması dışında uzun dönemde tekrarlayan üriner sistem enfeksiyonları, üst üriner sistemde dilatasyon ve böbrek yetmezliği gibi patolojilere yol açabilmesi açısından da önemli klinik ve ekonomik sonuçlar içermektedir [8].

Bu çalışmada amaç PSA yüksekliği nedeniyle transrektal ultrason (TRUS) eşliğinde biyopsi yapılan hastaların işlem öncesi PSA, uluslararası prostat semptom skoru (IPSS), maksimum idrar akım hızı (Qmax), hasta yaşı ve prostat hacmi değerleri ile patoloji spesmeninde saptanan kronik prostatit arasındaki ilişkinin değerlendirilmesidir.

Gereç ve Yöntem

Ocak 2012- Ocak 2014 tarihleri arasında ortalama yaşları 62 (45-75) olan transrektal ultrason (TRUS) eşliğinde biyopsi yapılan 152 hasta verisi retrospektif olarak değerlendirildi. Hastalara ortalama 10 kor (8-12) biyopsi yapılmıştı. Çalışmaya prostatik cerrahi geçirmemiş, üretral kateteri olmayan, aktif idrar yolu enfeksiyonu olmayan, parmakla rektal muayenede akut enflamasyon bulgusu bulunmayan ve patoloji sunucunda malignite saptanmayan hastalar dâhil edildi. Bu özellikleri içermeyen hastalar çalışmaya dâhil edilmedi. Hastaların dosyaları incelenerek anamnez, fizik muayene ve laboratuvar tetkik sonuçları kaydedildi. Anamnezlerde hasta yaşı, PSA düzeyini etkileyebilecek girişim öyküsü ve ilaç tedavileri, uluslararası prostat semptom skoru, işeme hacmi 130 mL’nin üzeri olan hastaların maksimum idrar akım hızı ve prostat hacmi (transrektal ultrason ile ölçülen) değerleri incelendi. Hastaların işlem öncesi ölçülen PSA değerleri ile patoloji sonuçları değerlendirildi. Biyopsi sonuçlarında kronik prostatit saptanan hastaların kronik prostatit içeren kor sayıları ve kronik prostatit içeren kor yüzdeleri (kronik prostatit içeren kor sayıları toplam alınan kor sayısına oranlanarak) hesaplandı. İşlem öncesi PSA, IPSS, Qmax, hasta yaşı ve prostat hacmi değerleri ile kronik prostatit içeren kor sayıları ve kor yüzdeleri arasındaki korelasyon değerlendirildi. Kronik prostatit saptanan hastalarla saptanmayan hastaların PSA, IPSS, Qmax, hasta yaşı ve prostat hacmi değerleri karşılaştırıldı.

İstatistiksel analiz

İşlem öncesi PSA, IPSS, Qmax, hasta yaşı ve prostat hacmi değerleri ile kronik prostatit içeren kor sayıları ve kor yüzdeleri pearson korelasyon analizi ile değerlendirildi. Kronik prostatit saptanan hastalarla saptanmayan hastaların PSA, IPSS, Qmax, hasta yaşı ve prostat hacmi değerleri ise student t testi ile değerlendirildi P<0.05 sonuçlar istatistiksel olarak anlamlı kabul edildi.

Bulgular

PSA, prostat hacmi, IPSS, Qmax, yaş, kronik prostatit içeren kor sayısı, kronik prostatit içeren kor yüzdesi ortalama değerleri tablo 1’de belirtilmiştir. Kronik prostatit içeren kor sayısı ile yaş (P=0.5, r=0.055) arasında istatistiksel olarak anlamlı korelasyon saptanmazken, kronik prostatit içeren kor sayısı ile IPSS (P<0.001, r= 0.646), prostat hacmi (P=0.04, r= 0.185) ve PSA (P=0.001, r= 0,309) ile istatistiksel olarak anlamlı derecede pozitif, Qmax (P<0.001, r= -0,628) ile ise negatif korelasyon saptandı (şekil 1). Kronik prostatit içeren kor yüzdesi ile yaş (P=0.3, r= 0.091) ve prostat hacmi (P=0.1, r= 0.143) arasında istatistiksel olarak anlamlı korelasyon saptanmadı. Fakat kronik prostatit içeren kor yüzdesi ile PSA (P<0.001, r= 0.325) ve IPSS (P<0.001, r= 0.625) arasında istatistiksel olarak anlamlı derecede pozitif korelasyon ve Qmax (P<0.001, r= -0.592) arasında ise negatif korelasyon saptandı. Çalışmamızda hastaların %74’ünün patoloji spesmeninde kronik prostatit içeren korlar saptanmıştır. Kronik prostatit saptanan hastaların IPSS (P<0.001), PSA(P<0.001) ve prostat hacmi (P=0.008) değerleri saptanmayan hastalara göre istatistiksel olarak anlamlı derecede daha yüksek iken Qmax (P<0.001) değerleri istatistiksel olarak anlamlı derecede daha düşük olarak saptandı. Hasta yaşları (P=0.961) arasında ise anlamlı fark yoktu (tablo 2).

Tartışma

Çalışmamızdan elde edilen verilerle histolojik olarak tespit edilen kronik prostatik enflamasyonun alt üriner sistem semptomları ile ilişkili olabileceği belirlendi. Amerika Birleşik Devletleri’nde her yıl yaklaşık olarak 2 milyon kadar hastanın prostatit benzeri şikâyetlerle kliniklere başvuru yapıldığı ve her yıl bu sayıya yaklaşık olarak 267 000 hastanın eklendiği bilinmektedir [2,9]. Benign prostat hiperplazisi nedeniyle rezeksiyon yapılmış olan prostat dokularının çoğunda enflamatuvar cevabın belirtilerine rastlanmaktadır. 12 haftalık embriyoda az miktarda da olsa prostat dokusu içerisinde saptanabilen enflamatuvar hücreler, yaş ilerledikçe giderek artmakta ve BPH nedeniyle yapılan ameliyatlardan elde edilen prostat dokularında çok daha yoğun olarak görülmektedir [10]. Daha önceki çalışmalarda enflamatuvar hücrelerin yaşla birlikte arttığı saptanmış olmasına rağmen bizim çalışmamızda yaş ile kronik prostatit kor sayısı arasında korelasyon saptanmadı. Ayrıca kronik prostatit saptanan hastalarla saptanmayan hastaların yaş ortalamaları yaklaşık aynı idi. Bu farklılığın bizim çalışmamızdaki hasta grubunun belli bir yaş üzeri olmasına bağlı olabileceği düşünülmüştür. Bu enflamatuvar hücre artışı çok daha önce başlıyor ve daha sonra bu enflamatuvar hücre yoğunluğu aynı seviyelerde kalıyor olabilir. Ancak bunun kesinleştirilmesi için ileri çalışmalara ihtiyaç vardır.

Benign prostat hiperplazisi (BPH) hastalarında serum prostat spesifik antijen düzeyi yüksekliği, sadece prostat hacminin artması nedeniyle değil aynı zamanda eşlik eden enflamasyonun yaptığı epitel hasarı sonucunda PSA’nın daha fazla kana karışması ile açıklanabilir [11]. Nonspesifik kronik enflamasyon, asinüslerin yırtılması sonrası prostatik sekresyonun stromaya sızması sonucunda gelişir [12]. Kronik prostatit saptanan hastaların PSA değerlerinin saptanmayan hastaların PSA değerlerinden istatistiksel olarak anlamlı derecede yüksek (P<0.001) saptanması önceki çalışmalarda olduğu gibi [11] enflamasyonun PSA’yı arttırdığını düşündürmüştür. Kronik prostatit içeren kor sayısı ve yüzdesinin PSA değerleri ile istatistiksel olarak anlamlı derecede korele olarak artması prostatik enflamasyonun PSA’yı enflamasyonun derecesiyle doğru orantılı olarak arttırdığını göstermiştir.

İn-vitro ve in-vivo çalışmalar sonucunda histolojik olarak BPH’nın oluşumunda kronik enflamasyonun rol oynadığı görülmektedir. Kronik prostatik enflamasyonun prostatta hacim artışında, BPH semptomlarının oluşumunda ve akut üriner retansiyon gelişmesinde bir risk faktörü olduğu saptanmıştır [10]. Çalışmamızda kronik prostatit saptanan hastaların prostat hacimleri saptanamayan hastaların prostat hacimlerinden istatistiksel olarak anlamlı derecede yüksek (P=0.008) bulundu. Bu sonuç önceki çalışmalardaki gibi kronik enflamasyonun prostat hacmi artışı ile ilişkili olabileceğini düşündürmüştür. Kronik prostatit içeren kor sayılarının prostat hacmi ile istatistiksel olarak anlamlı derecede korele olarak artması ise prostat hacmine olan etkisinin enflamasyon miktarı ile orantılı olabileceğini düşündürmüştür.

Di Silverio ve ark. çalışmalarında enflamasyonun BPH’nın klinik parametrelerinde bir kötüleşmeye neden olduğunu göstermişlerdir [13]. Çalışmamızda kronik prostatit içeren kor saptanan hastaların IPSS değerlerinin içermeyen hastalara göre istatistiksel olarak anlamlı derecede daha yüksek (P<0.001), Qmax değerlerinin ise daha düşük (P<0.001) bulunması kronik enflamasyonun BPH semptomları ile ilişkili olduğunu düşündürmüştür. Aynı şekilde kronik prostatit içeren kor sayısı ve yüzdesi ile IPSS değerleri arasında istatistiksel olarak anlamlı derecede pozitif, Qmax değerleri arasında ise negatif korelasyon saptanması enflamasyonun BPH semptomları ile ilişkili olduğunu ve ayrıca bu semptomlardaki artışın enflamasyonun seviyesi ile de ilişkili olduğunu göstermiştir.

Bir çalışmada erkek kronik prostatit hastalarında selektif COX-II inhibitörü kullanılmasının özellikle ağrı ve alt üriner sistem semptomlarında düzelme sağladığı bildirilmiştir. Aynı çalışmada selektif COX-II inhibitörü tedavisine alfa bloker eklenmesi ek bir tedavi etkinliği getirmediği saptanmıştır [14]. Alfa bloker kullanılması ile ilgili etkin sonuçların alınması için literatürde tanımlandığı gibi bu ilaçların en az 4-6 hafta boyunca kullanılmaları gerekmektedir [15]. Tüm prostatitlerin %90-95’ini oluşturan tip 3 kronik prostatitte alternatif tedavi arayışları hala sürmesine rağmen antibiyotik + antienflamatuvar + alfa bloker tedavisinin prostatit semptomlarına yararlı olduğu görülmüştür [16].

Sonuç olarak elde edilen veriler ile kronik prostatik enflamasyonun alt üriner sistem semptomları, prostat hacmi ve PSA değerleri ile ilişkili olduğu düşünülmüş olup bu konuda daha geniş araştırmalara ihtiyaç vardır. Ayrıca bu hastaların tedavi ve takibinde enflamasyonun göz önünde bulundurulması faydalı olabilir.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

 Kaynaklar

1. Krieger JN, Egan KJ, Ross SO, Jacobs R, Berger RE. Chronic pelvic pains represent the most prominent urogenital symptoms of “chronic prostatitis”. Urology 1996; 48(5):715-21.

2. Nickel JC. Prostatitler ve ilişkili durumlar. Campbell Üroloji (Partin K, Peters N, ed), (Anafarta MK, Yaman MÖ çeviri ed). Ankara: Güneş Kitabevi; 2006. 603.

3. Erdemir F, Parlaktaş BS, Uluocak N. Prostatitlerin Patofizyolojisi, tanısı, tedavisi ve değerlendirilmesindeki yenilikler. Üroloji Bülteni 2007; 18: 147- 55.

4. Daniels NA, Ewing SK, Zmuda JM, Wilt TJ, Bauer DC. Osteoporotic Fractures in Men Research G: Correlates and prevalence of prostatitis in a large community-based cohort of older men. Urology 2005; 66(5):964-70.

5. St Sauver JL, Jacobson DJ, McGree ME, Girman CJ, Lieber MM, Jacobsen SJ. Longitudinal association between prostatitis and development of benign prostatic hyperplasia. Urology 2008; 71(3):475-9

6. Nickel JC, Roehrborn CG, O’Leary MP, Bostwick DG, Somerville MC, Rittmaster RS. The relationship between prostate inflammation and lower urinary tract symptoms: examination of baseline data from the REDUCE trial. European urology 2008; 54(6):1379-84.

7. Schwinn DA, Roehrborn CG. Alpha1-adrenoceptor subtypes and lower urinary tract symptoms. International journal of urology : official journal of the Japanese Urological Association 2008; 15(3):193-9.

8. Wei JT, Calhoun E, Jacobsen SJ. Urologic diseases in America project: benign prostatic hyperplasia. The Journal of Urology 2005; 173(4):1256-61.

9. Schappert SM. National Ambulatory Medical Care Survey: 1991 summary. Vital and health statistics Series 13, Data from the National Health Survey 1994;(116):1-110.

10. Djavan B, Eckersberger E, Espinosa G, Kramer G, Handisurya A, Lee C, Marberger M, Lepor H, Steiner GE. Complex mechanisms in prostatic inflammatory response. European Urology Supplements 2009; 8(13):872-8.

11. Karazanashvili G. Editorial comment on: the relationship between prostate inflammation and lower urinary tract symptoms: examination of baseline data from the REDUCE trial. European Urology 2008; 54(6):1383-4.

12. Rosai Juan. Surgical Pathology. St. Louis: Mosby; 1996. 1221-318.

13. Di Silverio F, Gentile V, De Matteis A, Mariotti G, Giuseppe V, Luigi PA, Sciarra A. Distribution of inflammation, pre-malignant lesions, incidental carcinoma in histologically confirmed benign prostatic hyperplasia: a retrospective analysis. European Urology 2003; 43(2):164-75.

14. Ates M, Karalar M, Yıldırım B, Pektaş F, Ay C, Baykara M, Erdoğru T. The Effect of Rofecoxib/Doxazosin Treatment for Chronic Prostatitis/Chronic Pelvic Pain Syndrome in Men. Erkek Kronik Prostatit/Kronik Pelvik Ağrı Sendromunda Rofekoksib/Doksazosin Tedavi Etkinliği. J Clin Anal Med 2012;3:274-7

15. Atılgan D, Yaşar A, Erdemir F, Parlaktaş BS, Uluocak N, Fırat F. Comparison the Efficacy of Four Different Alpha Blockers in the Treatment of Benign Prostatic Hyperplasia. J Clin Anal Med 2011;2:27-31.

16. Erdemir F, Fırat F, Atılgan D, Uluocak N, Parlaktaş BS, Yaşar A. Tip 3 Kronik Prostatit (Kronik Pelvik Ağrı Sendromu) Üzerine Üç Farklı Tedavi Protokolünün Etkinliğinin Karşılaştırılması. J Clin Anal Med 2010; 1:26-30.

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Sebahattin Albayrak, Kursad Zengin, Serhat Tanik, Hasan Bakirtas, Muhammet Abdurrahim Imamaoglu, Mesut Gurdal. The Relationship of Histologically Diagnosed Chronic Prostatic Inflammation and Lower Urinary Tract Symptoms. J Clin Anal Med. 2015;6(6):733-736

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Relationship of Recurrent Aphthous Stomatitis with Nutritional Habits

Gül Soylu Özler 1, Ayşe Neslin Akkoca 2, Cengiz Cevik 1, Erhan Yengil 2

1 Department of Otorhinolaryngology, 2 Department of Family Medicine, Mustafa Kemal University, Hatay, Turkey

DOI: 10.4328/JCAM.2412 Received: 18.03.2014 Accepted: 02.04.2014 Published Online: 03.04.2014

Corresponding Author: Gül Soylu Özler, Mustafa Kemal University, Department of Otorhinolaryngology, Hatay, Turkey. T.: +90 3262293323 GSM: +905053980778 E-Mail: soylugul@yahoo.com

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Abstract

Aim: In this study we investigated the frequency and relationship of recur-rent aphthous stomatitis(RAS) with family history, personal variables such as weight, heigt, antibiotic usage, teeth brush and nutritional habits in geriatric patients. Material and Method: The patients over 65 years old were included in the study. Before examination, the definition of recurrent oral aphthous ulcers and a visual informatory form including photographs were presented to the subjects. The age, sex, height, weight of the subjects were noted on a chart. Then the history of recurrent oral aphthous ulcerations were asked and if present the frequency of the ulcers, the type of the ulcers, the localiza-tion of the ulcers, the subjective symptome of the ulcers, familial history for the ulcers, frequency of antibiotic usage, teeth brush habits and nutritional habits were examined by a questionnaire. Results: Eighty subjects completed the study. 31.25% of subjects declared recurrent oral ulcer history. Pain was the leading subjective symptome declared by 44% of the subjects. 15% of the subjects had a family history for recurrent oral ulcers. There was no cor-relation between frequency of antibiotic usage and history of RAS. Also, there was no correlation between teeth brush habits and history of RAS. The RAS group consumed tea and fizzdrinks more frequently whereas they consumed milk and milk products, walnut, bread and other grains more rarely. Discussion: Nutritional habits may have a role on ocurrence of reccurrent oral aphthous ulcerations. So we are of the opinion that the elimination of the risky nourishments and the addition of the protective nourishments may be the first step of the treatment period.

Keywords: Geriatrics; Recurrent Aphthous Stomatitis(RAS); Nutrition

Full Text

Introduction

Recurrent aphthous stomatitis(RAS) is a disease which presents as painful open sores inside the oral cavity characterized by a break in the mucous membrane. It may effect up to 20% of the population and women are more often affected than men[1].

Recurrent aphthous ulcers are classified according to the diameter of the lesion. Minor aphthous ulcers are 3-10 mm in diameter. They can be single or multiple. They heal spontaneously within 2 weeks. Major aphthous ulcers have the same appearance as minor ulcerations, but are greater than 10 mm in diameter and are extremely painful. They usually take more than a month to heal, and frequently leave a scar. These typically develop after puberty with frequent recurrences. Herpetiform ulcerations are the most severe form. It occurs more frequently in females, and onset is often in adulthood. It is characterized by small, numerous, 1–3 mm lesions that form clusters. They typically heal in less than a month without scarring[2].

The etiology of RAS still remains unknown. These ulcerations may be indicative of underlying systemic diseases ranging from vitamin deficiency to autoimmunity[3]. There are several studies investigating the role of genetics, stress, hematinic deficiencies, vitamin deficiencies, trauma, microbial agents and autoimmunity in the literature[4-8].

In this study we investigated the frequency and relationship of RAS in geriatric patients with family history, personal variables such as weight, height, antibiotic usage, teeth brush habits and nutritional habits.

Material and Method

Study design

This study is conducted at Mustafa Kemal University between November 2013 and January 2014. Ethics committee approval was obtained and was conducted adhering to the Declaration of Helsinki. Informed consent was obtained from all participants.

Study population and Progess of the study.

The patients who referred to ear nose throat and family medicine clinics over 65 years old were included in the study. Before examination, the definition of recurrent oral aphthous ulcers and a visual informatory form including photographs were presented to the subjects. The age, sex, height, weight of the subjects were noted on a chart. Then the history of recurrent oral aphthous ulcerations were asked and if absent the frequency of the ulcers, the type of the ulcers, the localization of the ulcers, the subjective symptome of the ulcers, familial history of the ulcers, frequency of antibiotic usage, teeth brush habits were examined by a questionnaire. Food consumption frequency questionnaire is the most common criteria of nutritional evaluation in epidemiological studies and has a standard form translated to Turkish[9]. So, food consumption frequency questionnaire were used to evaluate the nutritional habits of the subjects. In this questionnaire, nourishments were evaluated in 9 main groups:

1- Milk and milk products( full fat milk, half fat milk, full fat yoghurt, half fat yoghurt, full fat cheese, half fat cheese, skimmed cheese, butter milk)

2- Meat and meat products(fatty beef, lean beef, fatty mutton, lean mutton, chicken, turkey, fish, meat products, sweetbread)

3-Egg(whole egg, egg yolks, egg white, quail eggs)

4- Legume and oily pits(legume, walnut, hazelnut, peanut, pistachio nut, seed)

5- Bread and other grains(white bread, brown bread, white flat bread, brown flat bread, whole wheat bread,rye bread, macaroni, rice,cracked wheat,pastry,biscuits,cake)

6- Vegetables and fruits(green vegetables, yellow vegetables, potato, tomato, other vegetables, citrus fruits, summer fruits, dried fruits)

7- Oil(olive oil, canola oil, hazelnut oil, vegetable oil, margarine, butter, tail fat)

8- Sugar and desserts( sugar, desserts, honey, jam, sesame paste, molasses, chocolate)

9- Other(olive, tea,turkish coffee, instant coffee, alcohol beverages,fruit juices,fizzdrinks,turnip,pickles,spices,ketchup,mayonnaise)

The subjects were asked how often they consumed these 9 main groups and subgroups of nourishments. The options were every meal, every day in two meals, every day in one meal, once a week, twice or three days a week, 4 days a week, five or six days a week, three days or twice a month,once a month and never.

The same clinician filled the questionnaire and evaluated the parameters. The frequency of RAS in geriatric patients and relationship between RAS and family history, personal variables such as weight, height, antibiotic usage, teeth brush and nutritional habits in geriatric patients were evaluated.

Statistical Methods

The SPSS statistical software package (SPSS, version 19.0 for Windows; SPSS Inc, Chicago, IL) was used to perform all statistical calculations. Adequacy of all parameters to normal distribution was tested by using Kolmogorov-Smirnov test. Parametric tests were applied to values with normal distribution; nonparametric tests were used in those without normal distribution. Chi-square test was used to compare the categorical parameters between the groups. Independent-samples t test was used for statistical comparison of data that match with normal distribution, and Mann-Whitney U test was applied to compare data without normal distribution between the groups. Differences were considered statistically significant at p ≤ 0.05.

Results

Eighty subjects (36 men and 44 women) with a mean age of 74.83±8.131(age range 63 –108 years) completed the study. 25 of 80(31.25%) subjects declared recurrent oral ulcer history. 8 of 25(32%) subjects declared recurrent oral ulcers once a year, 9 of 25(36%) subjects declared one to three times a year, 8 of 25(32%) subjects declared three times a year. The localization of oral ulcers were buccal mucosa in 8 of 25(32%) subjects, labial mucosa in 7 of 25(28%) subjects, tongue in 4 of 25(16%) subjects, gingival mucosa in 3 of 25(12%) subjects, palatal mucosa in 2 of 25(8%) subjects and tonsilla palatina in1 of 25(4%) subjects.

The type of ulcers were declared as minor by 19 of 25(76%) subjects, major by 6 of 25(24%) subjects. No subject declared herpetiform oral ulcers.

Pain was the leading subjective symptome declared by 11 of 25(44%) subjects. Dyphagia in 2(8%) subjects, dining difficulty in dining4(16%)subjects, speaking difficulty in 4(16%) subjects,poor appetite in 2(8%) subjects were the other subjective symptomes. 2 of 25(4%) subjects declared that they had no subjective symptome caused by the oral ulcer.

12 of 80(15%) subjects had a family history for recurrent oral ulcers.

The frequency of antibiotic usage were as follows; once a year in 17( 21.3%) subjects, once in six months in 26( 32.5%) subjects, once in three months in 32 (40.0%) subjects, once a month in 4 (5.0%) subjects and once in fifteen days in 1( 1.3%) subject.

Teeth brush habits were as follows; twice a day in 2( 2.5%) subjects, once a day in 4( 5%) subjects, every other day in 45 (56.3%) subjects, once or twice a week in 12( 15%) subjects and once in fifteen days in 9 (11.3%) subjects.

Then the subjects that had a history of oral ulcers( RAS group) and did not have a history of oral ulcers(control group) were compared for demographic data, personal variables and nutritional habits. The analysis of the groups were not statistically different in terms of age and height(p=0.502, p=0.499) whereas the RAS group had statistically lower weight than the control group (p=0.018).

31(56.36%) of RAS group,13(52%) of control group were females. The groups were similar in terms of sex(p=0.716).

5 of 25(20%) subjects in RAS group,7 of 55(12.7%) subjects in control group had a family history for recurrent oral ulcers. The groups was not statistically different in terms of family history(p=0.3398).

There was no correlation between frequency of antibiotic usage and history of recurrent oral ulcers(p=0.549).

Also, there was no correlation between teeth brush habits and history of recurrent oral ulcers(p=0.138).

The analysis of correlation of nutritional habits and history of recurrent oral ulcers revealed no statistically significant difference for meat and meat products, egg, legume, hazelnut, peanut, pistachio nut, seed, vegetables and fruits, oil, sugar and desserts, olive, turkish coffee, instant coffee, alcohol beverages, fruit juices, turnip, pickles, spices, ketchup, mayonnaise(p≥ 0.05).On the other hand, there was correlation for milk and milk products, walnut, bread and other grains, tea and fizzdrinks(p≤0.05).The RAS group consumed tea(p=0.0001) and fizzdrinks(p=0.017) more frequently whereas they consumed milk and milk products(p=0.045), walnut (p=0.026), bread and other grains(p=0.0001) more rarely.

Discussion

In this study the frequency of RAS in geriatric patients and relationship between RAS and family history, personal variables such as weight, height, antibiotic usage, teeth brush and nutritional habits in geriatric patients were investigated.

RAS is common worldwide and may effect up to 20% of the population The prevalance of recurrent oral ulcers ranges from 5% to 50% up to the population investigated[10]. In our study 31.25% geriatric subjects declared recurrent oral ulcer history.

In our study there was no correlation between sex and history of RAS . In the literature, RAS was reported to be seen more frequently in women and have exacerbations in premenstrual period and regressions in pregnancy[10,11].

The analysis of the groups were not statistically different in terms of height, whereas the mean weight of the RAS group was statistically lower than the control group.

The most common form of RAS is minor aphthous ulceration, and the minor form is respectively followed by major and herpetiform ulcerations[12]. Minor form is 75-85 % ,major form is 10-15%, herpetiform form is 5-10% of all oral ulcerations. In our study, 76% of the subjects declared minor aphthous ulcerations, whereas 24% of the subjects declared major aphthous ulcerations. None declared herpetiform type.

The previous studies reported that oral ulcers occured more frequently on non-osseous sides of oral cavity[13]. In our study the most frequent localizations of oral ulcers were buccal mucosa and labial mucosa followed by tongue , gingival mucosa, palatal mucosa and tonsilla palatina.

Consistent with the literature, pain was the leading subjective symptome declared by 44% of the subjects[9]. Dyphagia, dining difficulty, speaking difficulty, poor appetite were the other subjective symptomes declared by the subjects in our study. 4% of the subjects declared that they had no subjective symptome caused by the oral ulcer. Fever, exhaustion, musculoskeletal pain, lymphadenopathy, nausea and vomitting are other reported symptomes declared by subjects with RAS in the literature [13,14].

20% of the subjects in RAS group,12.7% of the subjects in control group had a family history for recurrent oral ulcers. There are several studies reporting the role of genetics in the etiology of RAS but there is no consensus about the percentage of family history[13-15].

There was no correlation between frequency of antibiotic usage and teeth brush habits with history of RAS.

The etiology of RAS still remains unknown. Some authors believe that nutritional habits have o role on the occurence of recurrent oral ulcers. In previous studies cinnamon, gluten, cow milk, coffee, chocolate, potato, cheese, citrus fruits, strawberry tomato and spice are the most frequently detected nourishments consumed by the subjects having a history of RAS[16-20]. In studies conducted with elimination diets revealed that the elimination of tomato, lemon, vinegar, mustard, cheese, cow milk reduced the frequency of recurrent oral ulcers[18-20]. In another study, the subjects with RAS consumed tea and spice more frequently whereas they consumed walnut, bread and other grains and chocolate more rarely[9].

In our study, there was no correlation between history of RAS and meat and meat products, egg, legume, hazelnut, peanut, pistachio nut, seed, vegetables and fruits, oil, sugar and desserts, olive, turkish coffee, instant coffee, alcohol beverages,fruit juices, turnip, pickles, spices, ketchup, mayonnaise.On the other hand, there was correlation for milk and milk products, walnut, bread and other grains, tea and fizzdrinks. The RAS group consumed tea and fizzdrinks more frequently whereas they consumed milk and milk products, walnut, bread and other grains more rarely.

Geriatric subjects need a targeted approach to their diseases because they have special issues that are unique to this population. The previous studies investigated the frequency of RAS and relationship of RAS with personal variables and nutritional habits in the general population. In that respect this is the first study addressing the geriatric subjects.

The limitations of our study is the number of subjects we investigated. Mental disorders such as dementia and amnesia are seen more frequently in geriatric poulation, so we excluded the subjects that we were not sure about the reliance of the data they declared.

We believe that studies with larger number of RAS subjects and more detailed studies with the elimination of risky nourishments will be further beneficial.

Conclusion

Nutritional habits may have a role on ocurrence of reccurrent oral apthous ulcerations. So we are of the opinion that the elimination of the risky nourishments and the addition of the protective nourishments may be the first step of the treatment period.

Competing interests

The authors declare that they have no competing interests.

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Gul Soylu Ozler, Ayse Neslin Akkoca, Cengiz Cevik, Erhan Yengil. Relationship of Recurrent Aphthous Stomatitis with Nutritional Habits. J Clin Anal Med. 2015;6(6):729-732

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Early Surgical Treatment of Penile Fracture: Our Experience with 19 Patients

Ozer Guzel 1, Altug Tuncel 1, Tanju Keten 1, Melih Balci 1, Yilmaz Aslan 1, Muslum Yildiz 1, Ali Atan 2

1 Ministry of Health, Ankara Numune Research and Training Hospital, Third Department of Urology, 2 Gazi University, School of Medicine, Department of Urology, Ankara, Turkey

DOI: 10.4328/JCAM.2372 Received: 10.03.2014 Accepted: 31.03.2014 Published Online: 01.04.2014

Corresponding Author: Ozer Guzel, Ministry of Health, Ankara Numune Research and Training Hospital, Third Department of Urology, 06120, Ankara, Turkey. GSM: +905324301496 F.: +90 3123103460 E-Mail: drozerguzel@gmail.com

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Aim: We aimed to evaluate the outcomes of patients who underwent surgi-cal treatment due to penile fracture. Material and Method: Between 2007 and 2013, a total of 19 patients admitted to our hospital for penile fracture treated with early surgical repair were included in the study. In the pre-oper-ative period, Age, first-five questions version of International Index of Erectile Function (IIEF-5) scores, penile fracture etiology, penile fracture formation, duration until referred to our hospital and duration of hospitalization were retrospectively obtained from medical data of patients. In the post-operative period, IIEF-5 scores, loss of penile sensation, painful erection and penile curvature development were evaluated. Results: The mean age of patients was 37.8 years. The mean follow-up time was 33.4 months. The mean time until the surgery and pre-operative IIEF-5 score were 11.1 hours and 22.7, respectively. In pre-operative period, 1 patient had mild-moderate degree erectile dysfunction (ED), 3 patients had mild degree ED. Fifteen patients had no ED. The mean of post-operative IIEF-5 score was 19.3. There was a sig-nificant difference between pre-operative and post-operative IIEF-5 scores (p=0.01). In the post-operative period, penile curvature was detected in 5 (26.3%), painful penile erection in 4 (21%) and loss of penile sensation in 2 (%10.5) patients. Discussion: In light of our results, we believe that patients who undergo early penil fracture surgery should be well informed in terms of possible penile curvature, painful erections and ED development.

Keywords: Penile Fracture; Surgery; Complication

Full Text

Introduction

Penile fracture is one of the rare urological emergencies. It is defined as the rupture of tunica albuginea surrounding by the corpus cavernosum and corpus spongiosum. The usual cause is blunt trauma during the penile erection. [1]. Diagnosis of penile fracture is easy. It is based on history and physical examination findings, as accepted by many authors. Moreover, several diagnostic imaging modalities such as urethrography, cavernosography, ultrasonography, magnetic resonance imaging (MRI), and angiography could be used [2,3]. Although early surgical treatment is recommended, some complications such as erectile dysfunction (ED), painful penile erection and loss of penile sensation may be occur in the post-operative period [3,4].

In the present study, we aimed to evaluate results of patients who underwent early surgical treatment due to penile fracture.

 Material and Method

Between January 2007 and August 2013, 19 patients referred by the emergency service to our clinic due to penile fracture were included in the present study. Demographic and clinical information including age, first-five questions version of International Index of Erectile Function (IIEF-5) score, penile fracture etiology, fracture side, fracture formation, the time until the surgery and duration of hospitalization data were received from patient’s file retrospectively. During the initial evaluation of patients, presence of hematoma, edema, penile deviation and urethroragia were recorded. When found to have urethroragia, patients were evaluated with urethrography. Following a broad-spectrum antibiotic prophylaxis (with 1th or 2th generation cephalosporine), all patients underwent an operation for early surgical repair.

Initially, following urethral foley catheterization, incision of circumcision line was made and penile skin was degloved until the fracture zone is observed. After the fracture line was explicitly defined, this line was repaired with 2/0 or 3/0 polydioxanone suture (PDS). After filling corpus cavernosum with saline, leaks were evaluated from fracture line. Skin defect was primarily repaired and wrapped with elastic bandages. In the post-operative period, antibiotic and non-steroid anti-inflammatory drug (NSAID) therapy was administered. Urethral cathater was removed on post-operative 1th day and patients were discharged at the post-operative 1th or 2th day with appropriate oral antibiotic and NSAID therapy. Post-operative IIEF-5 score and development of painful erection, penile curvature and loss of penile sensation were recorded from patients data.

Statistical analysis

Statistical Package for Social Sciences (SPSS) for Windows (SPSS, Chicago, USA) version 13.0 software was used for statistical evaluation. A Wilcoxon signed rank test was used to compare pre-operative and post-operative IIEF-5 scores. A p value less than 0.05 was considered significant.

Results

The mean age of patients was 37.8±12.2 (23-66) years. The mean follow-up time was 33.4±24.3 (3-68) months. As regards etiologic factors for development of penile fracture, patients were declared that 6 patients (31.6%) sudden rotation during sleep in bed, 8 of patients (42.1%) during sexual intercourse, 4 of patients (21.1%) during masturbation in and falling out of bed in 1 patient (5.2%). The time from the development of penile fracture to the operation was 11.1±10.02 (4-48) hours. The mean of pre-operative IIEF-5 score was 22.7±3.2 (5-25). In the pre-operative period, 1 patient had mild-moderate degree ED (IIEF-5 score=12-16), 3 patients had mild degree ED (IIEF-5 score=17-21) and 15 patients had no ED (IIEF-5 score≥22).

The mean of post-operative IIEF-5 score was 19.3±5.9 (5-25). There was a significant difference between pre-operative and post-operative IIEF-5 scores (p=0.01). In the post-operative period, IIEF-5 scores did not change in 10 patients (%52.6). In patients preoperatively without ED (n=15), severe degree ED developed in 1 (%0.6), moderate degree ED developed in 1 (%0.6) and mild degree ED developed in 2 (%10.5) patients.

In the post-operative period, penile curvature (100-300) was detected in 5 (26.3%), painful erection in 4 (21.05%) and loss of penile sensation in 2 (%10.52) patients. In patients with painful erection, severe ED developed in 1 patient and IIEF-5 score decreased in remaning 3 patients. In these patients had mild- degree ED.

 Discussion

Penile fracture is described as the rupture of the tunica albuginea in the erected penis caused by sudden blunt force. It is an uncommon injury, but is a medical emergency. While the tunica albuginea thickness of penis is about 2 mm in the flaccid state, the thickness decreases about 0.25 to 0.5 mm during penile erection [1]. The most common cause of penile fracture are traumas during sexual intercourse in patient’s history [2]. Less often causes are the penis with hands is forced into flexion, the erected penis bended during sleep and falling out of bed [2-5]. Physical examination is usually sufficient for diagnosis. Common findings in physical examination of patients are hematoma on the rupture side, curvature toward the opposite side associated with edema. However, urethral injuries accompany penile fracture in about 10-33% of cases. Urethral injuries, urethroragia, hematuria or dysuria may occur. These cases must be evaluated by urethrogram [4]. Differences in the incidence of urethral injury may be due to differences in the methodology of studies. In some studies, microscopic hematuria is also considered as urethral injury [4,6]. In our study, urethroragia and difficulty urinating rather than microscopic hematuria was considered suggestive of urethral injury. Urethrography was required only in 2 patients who had difficulty urinating. Urinary leakage was not detected with urethrography in these patients.

In the international literature; elastic bandages, cold application and anti-inflammatory medications were recommended for treatment of penile fracture [7]. Mydlo et al. evaluated five patients conservatively treated due to the penile fracture in a study at 2001 [8]. They reported that these patients had normal erectile and voiding function after one-year follow-up. Mild degree penile curvature, which did not require treatment, was seen in only 1 patient. However, there are some studies reporting that fibrous tissue formation, penile deviation, prolongation of hospitalization and erectile dysfunction occur in approximately 30% of patients who underwent treatment with conservative approach [9-11]. This rate is reported to be about 10% in patients who underwent surgical treatment [12].

In recent years, early surgical treatment is widely recommended. Muentener et al. compared early surgical repair and conservative approach in a study of 29 patients with penile curvature [13]. While the success rate was found to be 92% in surgical treatment, this rate was found to be 59% in conservative approach. The authors emphasized that early surgical repair is more effective than conservative treatment. Similarly, in a study by Gedik et al., 6 patients who underwent conservative treatment and 101 patients who underwent surgical repair for penile fracture were evaluated [14]. For a 3 months follow-up, 18 (17.8%) of 101 patients had loss of penis and glans sensation in surgical repair group. These patients did not have ED. Howewer, 3 (50%) of 6 patients in conservative approach group had penile curvature which did not affect sexual intercourse. Authors stated that the surgical treatment is more effective than the conservative approach for prevention of penile curvature. In the present study, penile curvature (100-300) was observed in 5 (%26.3) patients and loss of penile sensation observed in 2 (%10.5) patients.

Similarly in a more recent study, Yamaçake et al. retrospectively evaluated 42 patients who underwent surgical or conservative treatment due to penile fracture [15]. They reported that, 31 cases (88.6%) of the surgical group and 4 cases (66.7%) of the conservative group had sufficient erections for intercourse, with no voiding dysfunction and no penile curvature during the 19.2 months follow-up. But, the remaining 2 patients (33.3%) from the conservative group developed ED and 3 patients (50%) developed penile deviation. They concluded that, surgical approach provides excellent functional outcomes and lower complications. Early surgical management of penile fracture provides superior results and conservative approach should be avoided.

It is known that, painful erections depending on the curvature may lead to ED [13-15].

In the present study, in 4 patients (5.21%) with penile curvature had painful erection. In one of patients with painful erection, severe ED was seen. Remaing of the patients had mild- degree ED.

The relationship between penile curvature and erectile dysfunction have been investigated extensively [3,9,13-16]. In a study, 21 patients with penile fracture were evaluated retrospectively in terms of post-operative sexual function [16]. They were able to establish contact with 17 patients. Fourteen patients demonstrated no evidence of ED, 1 patient reported symptoms of mild ED and one patient reported mild to moderate ED. Thirteen patients (83%) were reported to have a satisfactory sexual life according to Brief Male Sexual Function Inventory scale. Therefore, the authors reported that the early surgical treatment is promising in terms of long term sexual satisfaction. In the present study, the mean pre-operative and post-operative IIEF-5 scores were 22.7 and 19.3, respectively. Although the mean difference between preoperative and postoperative IIEF-5 scores was very small, it was statistically significant (p=0.01). In our follow-up period (mean 33.4 months), 4 patients had no ED in pre-operative period; among whom there was severe degree ED in 1 (0.6%), moderate degree ED in 1 (0.6%) and mild degree ED in 2 (10.5%).

In conclusion, we believe that patients who undergo early penile fracture surgery should be well informed in terms of possible penile curvature, painful erections and ED development.

Competing interests

The authors declare that they have no competing interests.

References

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14. Gedik A, Kayan D, Yamiş S, Yılmaz Y, Bircan K. The diagnosis and treatment of penile fracture: our 19-year experience. Ulus Travma Acil Cerrahi Derg 2011;17(1):57-60.

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16. Nason GJ, McGuire BB, Liddy S, Looney A, Lennon GM, Mulvin DW et al. Sexual function outcomes following fracture of the penis. Can Urol Assoc J 2013;7(7-8):252-7.

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Ozer Guzel, Altug Tuncel, Tanju Keten, Melih Balci, Yilmaz Aslan, Muslum Yildiz, Ali Atan. Early Surgical Treatment of Penile Fracture: Our Experience with 19 Patients. J Clin Anal Med. 2015;6(6):726-728

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Synthesis and Medicinal Evaluation of Mannich Bases Carrying Azetidinone Moiety

Kakarlapudi Ranga Raju 1, Aluru Raghavendra Guru Prasad 2, Badampudi Santosh Kumar 1, Lakshmana Rao Krishna Rao Ravindranath 1

1 Sri Krishnadevaraya University, Anantapur, A.P., 2 ICFAI Foundation for Higher Education, Hyderabad, A.P., India

DOI: 10.4328/JCAM.2408 Received: 17.03.2014 Accepted: 27.03.2014 Published Online: 28.03.2014

Corresponding Author: Aluru Raghavendra Guru Prasad, ICFAI Foundation for Higher Education, Hyderabad, A.P., India. T.: 91 98496 94428 E-Mail: guruprasadar@yahoo.co.in

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Aim: To synthesize, characterize and in vitro screen for antibacterial, antifun-gal and anthelmintic activity of series of Mannich bases carrying azetidinone moiety. Material and Method: The compounds were characterized by IR, 1H NMR and mass spectra and by elemental analysis. Their antimicrobial ac-tivity against the selected microorganism was found out by disk diffusion method. Anthelmintic activity studies were performed on Pheretima post-huma. Results: The antibacterial activity of the title compounds was com-pared with that of ciprofloxacin, antifungal activity with clotrimazole and anthelmintic activity was compared with that of piperazine citrate. Discus-sion: All the compounds showed significant antimicrobial activity in particu-lar, the activity of compounds 7c, 7e, 7f and 7h was comparable to that of standard antibiotics employed in the studies. Further, the compound 7h with N-methylpiperazine substituent showed anthelmintic activity comparable to that of the standard drug.

Keywords: Mannich Bases; Azetidinone Moiety; Antimicrobial Activity; Anthelmintic Activity

Full Text

Introduction

The simplest β-lactam possible is 2-azetidinone in which the nitrogen atom is attached to the β-carbon relative to the carbonyl group and is a part of the several β-lactam antibiotics namely penicillins, cephalosporins, carbapenems and monobactams. The 2-azetidinone template has been widely described as a lead structure for a wide spectrum of pharmacological activities. Hence the development of new synthetic methodology incorporating the β-lactam nucleus referred as β-lactam synthon method is a vigorous research approach in the current scenario. The activity of β-lactam antibiotics depends on the irreversible inhibition of bacterial cell wall synthesis. In particular, the D-alanyl-transpeptidase necessary for the murein synthesis of bacterial cell wall is inhibited [1]. Particularly a large number of 3-chloro monocyclic ß-lactams exhibit significant antimicrobial, anti-inflammatory, anticonvulsant, antitubercular etc activities [2-7]. They also function as enzyme inhibitors and are effective on the central nervous system [8, 9]. Due to the diverse nature of this scaffold, namely 2-azetidinones and in continuation of our search for novel pharmacologically active derivates [10-13], we herein report the synthesis and pharmacological evaluation of title compounds.

Material and Method

All chemicals and regents were procured from Merck India Limited. Nutrient broth, nutrient agar and 5 mm diameter antibiotic assay discs were obtained from Hi-Media Laboratories Limited, India. The standard bacterial and fungal strains were procured from National Centre for Cell Sciences, Pune, India. Synthesized compounds were recrystallized using suitable solvent. Melting points were determined by Scientific melting point apparatus, India and were uncorrected. Digital electronics balance (Shankar Scientific supplies, India), horizontal laminar air flow bench (Yorco sales Pvt. Ltd, New Delhi, India), incubator (Yorco sales Pvt. Ltd, New Delhi, India), zone reader (Cintex Industrial Corporation, India) and hot air oven were used for relevant investigations. Infrared spectra of the compounds were recorded in KBr discs on Perkin-Elmer FT IR spectrometer (υmax in cm-1). 1H NMR spectra were recorded on a JOEL (300 MHz) spectrometer using TMS as an internal standard (chemical shifts in δ).

Estimation of antimicrobial activity by Disc Diffusion Method

A suspension of Staphylococcus aureus was added to sterile nutrient agar at 45o C. The mixture was transferred to sterile petridishes to give a depth of 3 to 4 mm and allowed to solidify. Sterile discs of 5 mm diameter (Whatmann Filter paper) were immersed in solutions of synthesized compounds (20 μg/mL) and untreated control sample was also prepared for comparison.

A period of pre incubation diffusion (1 hour at room temperature) was ensured to minimize the effects of variations in time. The plates were incubated at 37o C for 24 hours and observed for antibacterial activity. The diameter of the zone of inhibition was measured for each plate in which the zone of inhibition was observed. The average zone of inhibition was calculated and compared with that of the standard. Similar procedure was adopted for studying the antimicrobial activity against the other organisms.

Procedure for anthelmintic studies

Adult earthworm, Pheretima posthuma, was collected from moist soil and washed with double distilled water. The earthworms of 5-6 cm in length were used in present investigations. Test samples were prepared at concentrations of 20 mg/mL in dimethylformamide. Six worms i.e. Pheretima posthuma, were placed in petri dish containing 50 mL of test solution. Piperazine citrate (10 mg/mL) was used as reference standard. Time corresponding to paralysis and death of the worm were determined.

Results and Discussion

Synthesis of ethyl 4,4,4-trichloro-3-oxo-2-(2-(4-substituted)phenyl hydrazono) butanoate (1)

Ethyl-4,4,4-trichloro-3-oxo-2-(2-phenyl hydrazono)-butanoate (1) was prepared by the procedure described by H.M.W.Alborsky and M.E.Baum [14].

Synthesis of 4-(2-(4-substituted)phenyl hydrazono)-3-(trichloro methyl)-1H-pyrazol-5(4H)-one (2)

A mixture of (1, 0.02 M), hydrazine hydrate (10 mL) and dimethyl formamide (10 drops) was subjected to microwave irradiation at 150 W intermittently at 30 seconds intervals for 2 minutes. After complete conversion as indicated by TLC, the reaction mixture was cooled and treated with cold water. The precipitated 3-methyl 4-(phenylhydrazono) pyrazoline-5-one (2a) was filtered and recrystallized from ethanol. Similar procedure was adopted for the synthesis of other compounds of the series 2b-f.

Synthesis of [5-Oxo-4-(4-substituted aryl hydrazono)-3-trichloro methyl-4,5-dihydro- pyrazol-1- yl]-acetic acid ethyl ester (3)

A mixture of (2) (0.02M), anhydrous K2CO3 (0.03M), chloro ethyl acetate (0.02M) and DMF was stirred at room temperature for 8 hours. The progress of the reaction was monitored by TLC using cyclohexane:ethylacetate (9:1) as elutent. After completion of the reaction, the reaction mixture was diluted with ice cold water. The solid separated was collected by filtration, identified as [5-Oxo-4-(phenyl hydrazono)-3-trichloromethyl-4, 5-dihydro-pyrazol-1- yl]-acetic acid ethyl ester (3a) and recrystallized from ethanol. Similar procedure was followed for the synthesis of other compounds 3b-f.

Synthesis of Ethyl 2-(3-chloro-2,5-dioxo-1-(phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetate (4a)

A solution of monochloroacetyl chloride (0.01 M, 20 mL) was added drop wise to a mixture of schiff’s base (3) (0.01 M), triethyl amine (0.02 M) in dioxane (25 mL) at room temperature. The progress of the reaction was monitored by TLC using cyclohexane:ethylacetate (9:1) as elutent. After completion of the reaction, the mixture was stirred for 8 hours and left undisturbed at room temperature for 3 days. The contents were poured on crushed ice, filtered and washed with sodium bicarbonate solution. The dried product was recrystallized from absolute alcohol. Similar procedure was adopted for the synthesis of other compounds 4b-f. The structures of the newly synthesized compounds were established by elemental, IR and 1H NMR spectral analysis.

IR(KBr) spectrum of ethyl 2-(3-chloro-2,5-dioxo-1-(phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetate (4a) shows signals at around 3340 cm-1, 1690 cm-1 and 677 cm-1 due to stretching vibrations of –OH, >C=O, C-Cl respectively.

1H NMR Spectrum of 4a shows signals at 4.6 (s, 1H, -OH), 5.16 (d, 1H, -CH of azetidin attached to phenyl ring), 5.44 (d, 1H, -CH of azetidin attached to –Cl), 6.57 (d, 1H, -CH), 6.76 (d, 1H, -CH), 7.12-7.21 (m, 5H of C6H5), 7.9-8.8 (m, 3H of quinoline ring).

Synthesis of 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetohydrazide (5a-f)

A mixture of ethyl 2-(3-chloro-2,5-dioxo-1-(phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetate (4a) (0.01 M) and hydrazine hydrate (0.015 M) in ethanol (20 mL) was refluxed for 5 hours. The reaction mixture was cooled and poured on to ice cold water with stirring. The progress of the reaction was monitored by TLC with acetone:ethyl acetate (7:3) as eluent. The solid separated was filtered, washed with water and recrystallized from ethanol to give 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetohydrazide.

IR(KBr) spectrum of 2-(3-chloro-2,5-dioxo-1-(phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)acetohydrazide (5a) shows signals at 3320 cm-1, 1660 cm-1 and 687 cm-1 due to stretching vibrations of –OH, >C=O, C-Cl respectively.

1H NMR spectrum of 5a shows signals at 4.5 (s, 1H, -OH), 5.19 (d, 1H, -CH of azetidin attached to phenyl ring), 5.39 (d, 1H, -CH of azetidin attached to –Cl), 6.67 (d,1H,-CH), 6.52 (d, 1H, -CH), 7.01-7.17 (m, 5H of C6H5), 7.74-8.66 (m, 3H of quinoline ring).

Synthesis of 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)-N’-((3-methyl-5-oxo-4,5-dihydro-1H-pyrazol-4-yl)methylene)acetohydrazide (6a-f)

Equimolar quantities (0.01 M) of 3-methyl-5-oxo-4,5-dihydro-1H-pyrazole-4-carbaldehyde and the corresponding amino compound (5a-f) were dissolved in warm ethanol (40 mL) containing DMF (0.5 mL). The reaction mixture was refluxed for 1-4 hours and then kept overnight at room temperature. The progress of the reaction was monitored by TLC using cyclohexane:ethylacetate (9:1) as an eluent. After completion of the reaction, the resulting solid was filtered, washed with ethanol, dried and recrystallized from ethanol to afford compounds 6a-f.

Synthesis of 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)-N’-((3-methyl-5-oxo-1-(morpholin/piperidin/N-methylpiperazine-1-ylmethyl)-4,5-dihydro-1H-pyrazol-4-yl)methylene)acetohydrazide (7a-h)

A mixture of (6a) (0.1 M), morpholine (0.15 M) and water (20 mL) was thoroughly stirred to obtain a clear solution. HCHO and DMF (0.05 M each, 3 mL) in ethanol were added to the above mixture at 0oC, stirred for 2 hours in an ice bath and left overnight at room temperature. The white solid obtained was isolated and recrystallized from ethanol to give Compound (7a). The reaction procedure leading to 7a was extended for the syntheses of (7b-h).

Characterisation of 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)-N’-((3-methyl-5-oxo-4,5-dihydro-1H-pyrazol-4-yl)methylene)acetohydrazide (6a-f)

Compound: m.p. oC; Yield (%); Molecular formula; Elemental Analysis: Element Found% (Calculated%); IR spectral data: IR νmax in cm– 1(Group); 1H NMR spectral data: (300 MHz, DMSO-d6) δ ppm.

6a: 198-9; 69; C19H16Cl4N8O4; C 40.51 (40.59), H 2.95 (2.87), N 19.88 (19.93); 3222 (NH of pyrazoline), 1690 (C=O of azetidine), 1592 (C=N), 687 (C-Cl of azitidine); 1.98(s, 3H, -CH3 attached to pyrazolone), 4.05 (s, 2H, -COCH2), 5.44(d, 1H, -CH of azetidine attached to Cl), 6.92-7.39(m, 5H, C6H5), 7.05(s, 1H, pyrazolone NH), 7.52(d, 1H, =CH-), 8.09(s, 1H, hydrazide NH), 9.04(s, 1H, Ar-NH).

6b: 206-7; 61; C20H18Cl4N8O4; C 41.65 (41.69), H 3.18 (3.15), N 20.41 (19.45); 3225 (NH of pyrazoline), 1660 (C=O of azetidine), 1684 (C=N), 690 (C-Cl of azitidine); 1.81(s, 3H, -CH3 attached to pyrazolone), 2.34 (s, 3H, -CH3), 4.12 (s, 2H, -COCH2), 5.34(d, 1H, -CH of azetidine attached to Cl), 6.92-7.39(m, 4H, C6H4), 7.05(s, 1H, pyrazolone NH), 7.50(d, 1H, =CH-), 7.99(s, 1H, hydrazide NH), 8.57(s, 1H, Ar-NH).

6c: 212-3; 60; C20H18Cl4N8O5; C 40.02 (40.56), H 3.01 (3.06), N 20.92 (18.95); 3223 (NH of pyrazoline), 1656 (C=O of azetidine), 1688 (C=N), 687 (C-Cl of azitidine); 1.88(s, 3H,-CH3 attached to pyrazolone), 3.83 (s, 3H, -OCH3), 4.09 (s, 2H, -COCH2), 5.61(d, 1H, CH of azetidine attached to Cl), 6.72-6.91(m, 4H, C6H4), 7.07(s, 1H, pyrazolone NH), 7.55(d, 1H, =CH-), 8.01(s, 1H, hydrazide NH), 8.81(s, 1H, Ar-NH).

6d: 217-8; 59; C21H20Cl4N8O5; C 41.29 (41.60), H 3.36 (3.33), N 18.4 4 (18.48); 3218 (NH of pyrazoline), 1648 (C=O of azetidine), 1689 (C=N), 685 (C-Cl of azitidine); 1.32 (q, 3H, -CH3 of ethoxy), 1.77(s, 3H, -CH3 attached to pyrazolone), 4.07 (t, 2H, -OCH2 of ethoxy), 4.01(s, 2H, -COCH2), 5.53(d, 1H, CH of azetidine attached to Cl), 6.69-6.89(m, 4H, C6H4), 7.08(s, 1H, pyrazolone NH), 7.56(d, 1H, =CH-), 8.02(s, 1H, hydrazide NH), 8.73(s, 1H, Ar-NH).

6e: 197-8; 65; C19H15Cl5N8O4; C 38.52 (38.25), H 2.55 (2.53), N 18.89 (18.78); 3228 (NH of pyrazoline), 1645 (C=O of azetidine), 1679 (C=N), 692 (C-Cl of azitidine); 2.01(s, 3H,-CH3 attached to pyrazolone), 4.08 (s, 2H, -COCH2), 5.50(d, 1H, CH of azetidine attached to Cl), 6.76-7.39(m, 4H, C6H4), 7.12(s, 1H, pyrazolone NH), 7.62(d, 1H, =CH-), 8.00(s, 1H, hydrazide NH), 9.05(s, 1H, Ar-NH).

6f: 202-3; 58; C19H15Br Cl4N8O4; C 35.59 (35.60), H 2.31 (2.36), N 17.41 (17.48); 3220 (NH of pyrazoline), 684 (C=O of azetidine), 1647 (C=N), 683 (C-Cl of azitidine); 2.09(s, 3H,-CH3 attached to pyrazolone), 4.08 (s, 2H, -COCH2), 5.51(d, 1H, CH of azetidine attached to Cl), 6.73-7.49(m, 4H, C6H4), 7.11(s, 1H, pyrazolone NH), 7.61(d, 1H, =CH-), 8.01(s, 1H, hydrazide NH), 9.05(s, 1H, Ar-NH).

Characterisation of 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)-N’-((3-methyl-5-oxo-1-(morpholin/piperidin/N-methylpiperazine-1-ylmethyl)-4,5-dihydro-1H-pyrazol-4-yl)methylene)acetohydrazide (7a-h)

Compound: m.p. oC; Yield (%); Molecular formula; Elemental Analysis: Element Found% (Calculated%); IR spectral data: IR νmax in cm–1(Group); 1H NMR spectral data: (300 MHz, DMSO-d6) δ ppm.

7a: 195-6; 61; C24H25Cl4N9O5; C 43.53 (43.59), H 3.83 (3.81), N 19.11 (19.06); 3205 (Ar-NH), 1690 (C=O of azitidinone), 1617 (C=O of pyrazolone), 1592 (C=N), 687 (C-Cl of azitidine); 1.89(s, 3H, -CH3 attached to pyrazolone), 3.91 (s, 2H, -COCH2), 5.64(d, 1H,- CH of azetidine attached to –Cl), 6.92-7.39(m, 5H, C6H5), 7.59(d, 1H, =CH), 7.97(s, 1H, hydrazide NH), 8.89(s, 1H, Ar-NH), 3.52 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.45 (t, 4H, -CH2-N-CH2 of morpholine ring), 4.85 (s, 2H, -N-CH2-N-).

7b: 214-5; 58; C25H27Cl4N9O5; C 44.41 (44.46), H 4.06 (4.03), N 18.61 (18.67); 3206 (Ar-NH), 1660 (C=O of azitidinone), 1616 (C=O of pyrazolone), 1684 (C=N), 690 (C-Cl of azitidine); 1.79(s, 3H, -CH3 attached to pyrazolone), 2.34 (s, 3H, -CH3), 4.03 (s, 2H, -COCH2), 5.49(d, 1H, -CH of azetidine attached to Cl), 6.75-7.12(m, 4H, C6H4), 6.92-7.39(m, 5H, C6H5), 7.53(d, 1H, =CH), 7.91(s, 1H, hydrazide NH), 8.61(s, 1H, Ar-NH), 3.51 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.46 (t, 4H, -CH2–N–CH2 of morpholine ring), 4.86 (s, 2H, -N-CH2-N-).

7c: 219-0; 54; C25H27Cl4N9O6; C 43.39 (43.43), H 3.91 (3.94), N 18.19 (18.23); 3208 (Ar-NH), 1656 (C=O of azitidinone), 1621 (C=O of pyrazolone), 1688 (C=N), 687 (C-Cl of azitidine); 1.86(s, 3H, -CH3 attached to pyrazolone), 3.83 (s, 3H, -OCH3), 4.01 (s, 2H, -COCH2), 5.68(d, 1H, -CH of azetidine attached to Cl), 6.72-6.91(m, 4H, C6H4), 7.60(d, 1H, =CH), 7.95(s, 1H, hydrazide NH), 8.51(s, 1H, Ar-NH), 3.50 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.42 (t, 4H, -CH2-N-CH2 of morpholine ring), 4.83 (s, 2H, –N–CH2–N–).

7d: 222-3; 45; C26H29Cl4N9O6; C 44.22 (44.27), H 4.17 (4.14), N 17.81 (17.87); 3210 (Ar-NH), 1648 (C=O of azitidinone), 1618 (C=O of pyrazolone), 1689 (C=N), 685 (C-Cl of azitidine); 1.32 (q, 3H, -CH3 of ethoxy), 1.71(s, 3H,-CH3 attached to pyrazolone), 4.06 (s, 2H, -COCH2), 4.07 (t, 2H, -OCH2 of ethoxy), 5.69(d, 1H, -CH of azetidine attached to Cl), 6.69-6.89(m, 4H, C6H4), 7.62(d, 1H, =CH), 7.94(s, 1H, hydrazide NH), 8.49(s, 1H, Ar-NH), 3.51 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.42(t, 4H, -CH2-N-CH2 of morpholine ring), 4.84 (s, 2H, -N-CH2-N-).

7e: 234-5; 50; C24H24Cl5N9O5; C 41.39 (41.43), H 3.54 (3.48), N 18.15 (18.12); 3209 (Ar-NH), 1645 (C=O of azitidinone), 1620 (C=O of pyrazolone), 1679 (C=N), 692 (C-Cl ofazitidine); 1.93(s, 3H, -CH3 attached to pyrazolone), 4.10 (s, 2H, -COCH2), 5.59(d, 1H, -CH of azetidine attached to Cl), 6.76-7.39(m, 4H, C6H4), 7.69(d, 1H, =CH), 7.90(s, 1H, hydrazide NH), 8.93(s, 1H, Ar-NH), 3.49 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.43 (t, 4H, -CH2-N-CH2 of morpholine ring), 4.81 (s, 2H, -N-CH2-N-).

7f: 238-9; 51; C24H24BrCl4N9O5; C 38.91 (38.94), H 3.29 (3.27), N 17.06 (17.03); 3210 (Ar-NH), 1684 (C=O of azitidinone), 1615 (C=O of pyrazolone), 1647 (C=N), 684 (C-Cl of azitidine); 2.01(s, 3H, -CH3 attached to pyrazolone), 4.09 (s, 2H, -COCH2), 5.61(d, 1H, -CH of azetidine attached to Cl), 6.73-7.49(m, 4H of C6H4), 7.65(d, 1H, =CH), 7.89(s, 1H, hydrazide NH), 8.92(s, 1H, Ar-NH), 3.50 (t, 4H, -CH2-O-CH2 of morpholine ring), 2.43 (t, 4H, -CH2-N-CH2 of morpholine ring), 4.81 (s, 2H, -N-CH2-N-).

7g: 201-2; 50; C25H27Cl4N9O4; C 45.59 (45.54), H 4.20 (4.13), N 19.17 (19.12); 3205 (Ar-NH), 1690 (C=O of azitidinone), 1617 (C=O of pyrazolone), 1592 (C=N), 687 (C-Cl of azitidine); 1.30–1.51 (m, 6H (CH2)3 of piperidine ring), 2. 10 (t, 4H, -CH2-N-CH2 of piperidine ring), 4.85 (s, 2H, -N-CH2-N-), 1.98(s, 3H,-CH3 attached to pyrazolone), 4.05 (s, 2H, -COCH2), 5.44 (d, 1H, -CH of azetidine attached to Cl), 6.92-7.39(m, 5H of C6H5), 7.52(d, 1H, =CH), 8.09 (s, 1H, hydrazide NH), 9.04(s, 1H, Ar-NH), 3.52 (t, 4H, –CH2–O–CH2 of morpholine ring), 2.45 (t, 4H, -CH2-N-CH2 of morpholine ring), 4.85 (s, 2H, -N-CH2-N-).

7h: 219-0; 55; C25H28Cl4N10O4; C 44.49 (44.53), H 4.22 (4.19), N 20.81 (20.77); 3205 (Ar-NH), 1690 (C=O of azitidinone), 1617 (C=O of pyrazolone), 1592 (C=N), 687 (C-Cl of azitidine); 2.26 (s, 3H, N-CH3), 2.45 (t, 4H, -CH2-N-CH2 of piperazine ring), 4.75 (s, 2H, -N-CH2–N-), 2.32 (t, 4H, -CH2-N(CH3)-CH2, 1.98(s, 3H, -CH3 attached to pyrazolone), 4.00 (s, 2H, -COCH2), 5.41(d, 1H, -CH of azetidine attached to Cl), 6.72-7.15(m, 5H of C6H5), 7.52(d, 1H, =CH), 8.09(s, 1H, hydrazide NH), 9.01(s, 1H, Ar-NH).

Antimicrobial activity

The antimicrobial activity of compounds was explored by the disc diffusion method [15] against selected microorganisms. The gram positive bacteria screened were Staphylococcus aureus NCCS 2079 and Bacillus cereus NCCS 2106. The gram negative bacterial screened were Escherichia coli NCCS 265 and Pseudomonas aeruginosa NCCS2200. The fungi screened were Aspergillus niger nccs 1196 and Candida albicans NCCS 3471.

The results shown in Figure 1 revealed that all compounds were active against the tested microbes and demonstrated high to moderate activity as compared to standards. It was interesting to note that among the compounds synthesized, compounds 7c, 7e, 7h and 7f were more sensitive to the tested organisms. Hence it can be inferred that the presence of halogen group and methoxy group at 4 position i.e. compounds 7c, 7e and 7h exhibited potent antimicrobial activity. Also presence of N-CH3 group in piperazine ring i.e compound 7f has exhibited remarkable antimicrobial and anthelmintic activity. The result pertaining to anthelmintic activity has once again witnessed the anthelmintic action of entire class of piperazine-containing compounds.

 Anthelmintic activity

Anthelmintic activity studies were performed on Pheretima posthuma. The results are given in their Table 1.The selection of Pheretima posthuma for anthelmintic studies is owing to its anatomical and physiological resemblance with the intestinal roundworm parasites of human beings [16-18]. Time for paralysis was noted when no movement of any sort could be observed except when the worms were shaken vigorously. Time for death of worms was recorded after ascertaining that worms did not move when shaken vigorously or even when dipped in warm water (at 50 oC) followed with fading away of their body colors.

Conclusion

A series of eight novel 2-(3-chloro-2,5-dioxo-1-(4-substituted phenylamino)-8-(trichloromethyl)-1,6,7-triazaspiro[3.4]oct-7-en-6-yl)-N’-((3-methyl-5-oxo-1-(morpholin/piperidin/N-methylpiperazine-1-ylmethyl)-4,5-dihydro-1H-pyrazol-4-yl)methylene)acetohydrazides has been synthesized and characterized. While all the novel compounds were active against certain bacteria and fungi, the compounds 7c, 7e, 7f and 7h were found to exhibit significant antimicrobial activity . It was also found that the compound 7h containing N-methylpiperazine moiety showed remarkable anthelmintic activity.

Competing interests

Authors declare that there are no competing interests concerning this article.

References

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Kakarlapudi Ranga Raju, Aluru Raghavendra Guru Prasad, Aluru Raghavendra Guru Prasad Raghavendra Guru Prasad, Badampudi Santosh Kumar, Lakshmana Rao Krishna Rao Ravindranath. Synthesis and Medicinal Evaluation of Mannich Bases Carrying Azetidinone Moiety. J Clin Anal Med. 2015;6(6):720-725

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The Effect of Computed Tomography on Surgeon’s Decisions in Suspected Appendicitis Cases

Alaattin Öztürk 1, Hakan Bozkurtoğlu 2, Yeşim Üçkurt 3, Cengiz Kaya 4, Zuhal Demirhan Yananlı 1, Ömer Faruk Akıncı 1

1 Fatih Üniversitesi Tıp Fakültesi, Genel Cerrahi Kliniği, Ankara, 2 Central Hospital, Genel Cerrahi Kliniği, İzmir, 3 Fatih Üniversitesi Tıp Fakültesi, Radyoloji Kliniği, Ankara, 4 Pendik Devlet Hastanesi, Genel Cerrahi Kliniği, İstanbul, Türkiye

DOI: 10.4328/JCAM.2382 Received: 11.03.2014 Accepted: 27.03.2014 Published Online: 28.03.2014

Corresponding Author: Alaattin Öztürk, Fatih Üniversitesi Tıp Fakültesi, Genel Cerrahi Kliniği, Yalı Mh. Sahil Yolu Sk. No:16 34844 Maltepe, İstanbul, Türkiye. T.: +90 2164589000 F.: +90 2163528359 GSM: +905324156301 E-Mail: aloz1969@yahoo.com

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Abstract

Aim: The purpose of this study is to evaluate the effect of computed to-mography (CT) on the diagnosis and treatment plan of surgeons in patients with suspected appendicitis. Material and Method: Our study was conducted between 2010 – 2011. One hundred twenty five patients suspected ap-pendicitis and underwent abdominal computed tomography scanning were enrolled. The effects of CT scanning on the diagnosis and treatment plan of surgeons were evaluated. Results: After CT scanning the findings of ap-pendicitis was revealed in 89 patients were not revealed in 36. Eighty eight patients diagnosed with acute appendicitis after a CT scan and the 5 pa-tients with clinical suspect of appendicitis which is not confirmed by CT scan were operated (total 93 patients). In according to histopathological findings acute appendicitis were confirmed in 83 patients and were not confirmed acute appendicitis in 10 patients. According to our study, CT has changed the diagnosis and treatment plan in 98 patients (78.4%) with suspected appendi-citis. The diagnosis of acute appendicitis was confirmed in 65 (52%) of these patients, and treatment was started ending the observation. Diagnostic and treatment plan was changed in 33 patients and CT did not affect surgeon’s decision in 27 (21.6%) patients. Discussion: CT is a diagnostic method which affects the diagnosis and treatment of patients with suspected appendicitis. We recommend CT scans without waiting in patients with suspected acute appendicitis.

Keywords: Appendectomy; Tomography; Abdominal Pain

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Introduction

Acute appendicitis (AA) is a frequent surgical disease. A physical examination, complete blood count, and sometimes ultrasonography (US) are usually sufficient to diagnose AA. If these investigations are not sufficient, abdominal computed tomography (CT) can be used to diagnose. CT has exceeds 90% sensitivity and specificity in diagnosis for AA [1]. But routine use of CT is still controversial.

There are many studies which evaluated the benefit of CT in diagnosing appendicitis, but only a few studies describe how CT use affected the surgeon’s decisions in suspected appendicitis. Some studies have reported that CT has a contribution in diagnosis, while others have reported that CT is unnecessary or even harmful [2].

In this study, we tried to examine the effect of abdominal CT on the diagnosis and treatment in patients with suspected appendicitis.

Material and Method

This prospective study was conducted prospectively between July 2010 and November 2011. The study was approved by the local ethics committee. One hundred twenty five patients with suspected appendicitis and abdominal CT scan were enrolled. Patients who had a definitive diagnosis and treatment without the use of a CT scan were excluded.

Patients’ complaints and physical examination findings, complete blood count, urinalysis, plain abdominal X-ray and US results were recorded. After diagnostic tests, suspected AA was determined for patients. An abdominal CT was performed to clarify the diagnosis in patients. The reasons for CT scanning are listed in table 1.

Multi-slice CT without contrast was performed for all patients. CT images were assessed immediately by radiologists after the scanning. The diagnostic criteria for AA on CT were the expansion of the appendix diameter more than 8 mm, the presence of appendicolith, periappendicular fluid collection, increased thickness of the appendix wall, and the appearance of inflammation in mesoappendix. The management of patients was planned according to the result of the CT.

Patients with at least one of these findings in abdominal CT scan in addition to clinical signs and symptoms were diagnosed with AA. Patients with diagnosis of AA were operated upon. The remaining patients were given medical treatment.

The diagnosis before and after the CT scan and the effects of using a CT scan on surgeon’s treatment plan was recorded. The results of the surgery and pathologic findings were also recorded. Pathological results were compared with the preoperative diagnosis. Patients with histopathologically normal appendixes and those having non-appendicitis pathology were classified as negative appendectomy.

Results

During the study period, 243 patients were operated because of appendicitis and 125 of these patients were enrolled in the study. The median age of the patients were 33 (range 5-85 years), and 73 (58,4%) were male and 52 (41,6%) were female.

The most common reason for CT scanning was a need of confirmation for clinical suspect of AA (52 patients). After CT scanning, the most frequent radiologic diagnosis was AA (89 patients). CT scan findings were not compatible with AA in 36 patients. No pathological finding was seen in CT scan of 14 patients in this group and there were other pathologies in 22.

Eighty eight patients diagnosed with AA after a CT scan and the 5 patients with clinical suspect of appendicitis which is not confirmed by CT scan were operated (total 93 patients). One patient with radiologic findings of AA was not operated due to inadequate clinical findings (Figure 1). According to the results of histopathology, AA was confirmed in 83 patients except for 10, including 6 normal appendixes, two inflammation of epiploic appendix, one cecal perforation, and one ovarian cyst rupture. AA was revealed in four of five patients whose operated according to clinical findings. Histopathologic findings in operated patients are given in table 2. According to the results of histopathology, the negative appendectomy rate in the study was 10.8%.

The use of CT changed the clinical diagnosis and treatment plan of surgeon in 98 patients (78.4%), but had no effect in 27 patients (21.6%). The most important effect of CT was to determinate an ultimate diagnosis and to terminate the observation (%52). Eighteen of the 27 patients whose treatment plan was not changed by their CT results had appendicitis and 9 had other diagnoses (Table 3).

Seven (25.9%) of the 27 patients whose treatment plan was not changed by CT scan were female and 20 (74.1%) were male. Forty-five (45.9%) of the 98 patients whose treatment has been changed by CT scan were female and 53 (54.1%) were male.

In our study, the sensitivity, specificity, positive predictive value, negative predictive value and the overall accuracy of CT were 95.1%, 76.1%, 98.7%, 88.8% and 88.8% respectively.

Discussion

Appendicitis is the most frequently diagnosed disease in patients with right lower quadrant abdominal pain. Detecting the presence or absence of acute appendicitis is essential for treatment planning.

CT scans may not be necessary for every patient presenting with abdominal pain, but it can be useful in making a definitive diagnosis when other investigation methods are not adequate for diagnosis or when exclusion of other pathologies are required. The surgeon generally makes a pre-diagnosis and treatment plan before CT scanning in patients presenting with abdominal pain. It is important to understand how the CT scan affects this process, because it could encourage routine use of CT scans in these cases.

The increased rate of negative appendectomy has led to a search for more efficient methods for accurate diagnosis. The use of CT, especially in suspicious cases, was found to decrease the rate of negative appendectomy. Studies have shown that while the rate of negative appendectomy without CT was 16-24%, CT use decreased it to 5% [1,3,4]. A meta-analysis found that negative appendectomy pre-CT was 21.5% but decreased to 10% with the use of CT scans. We found that the rate of negative appendectomy is 10.8%. CT was found to be more helpful in female patients [4]. In a study by Coursey et al, the use of CT was found to decrease the rate of negative appendectomy only in female patients younger than 45 years of age. The rate was similar in males and older females [5]. However, some studies did not find any significant difference with the use of CT [6].

The sensitivity and specificity of CT for diagnosis of appendicitis is quite high, and reported to be 87-100% and 83-100% respectively [3,7,8]. The overall accuracy, positive predictive value and negative predictive value of CT were reported to be 94-98%, 92-98% and 95-100% respectively [8,9]. We found similar results in our study.

Although the use of intravenous contrast material is advised for the diagnosis of appendicitis, unenhanced CT scans may also be used [10]. We did not used contrast in patients, and preferred not to use contrast materials when possible because oral and rectal contrast material use is time-consuming and uncomfortable for patients. Oral, intravenous, and rectal contrast materials can be used depending on the individual patient’s clinical status. In one study, where a definitive diagnosis was made in 75% of patients, contrast CT was reserved for those who could not be diagnosed by plain CT [11].

The effect of CT on treatment plans is quite high because of its high sensitivity and specificity. In one study, it was found that CT influenced the diagnosis and/or treatment of 45.6% of patients [10]. In our study, this value was 78.4% (98 patients). This high rate is expected because definitive diagnosis was not made with other tests and the CT scan was expected to aid in the diagnosis and treatment planning process.

Other studies showed that CT affects the treatment of appendicitis by avoidance of unnecessary appendectomy, avoidance of unnecessary observations, and exclusion of other pathologies [1,10,12,13]. By avoiding unnecessary operations, CT reduces the cost of treatment [14]. Especially appendagitis epiploica located in the right colon should be considered in the differential diagnosis. Because acute appendicitis need surgical intervention while epiploic appendagitis can be recovered by medical treatment [15,16]. The differential diagnosis of these two diseases can be made by CT. In our study, the most common effect of CT was a more definitive diagnosis of appendicitis. As a result, the surgeon started the surgery with a more accurate diagnosis and the patients consented to the operation more easily. Another effect of CT is the change of the incision; this change is important because control of a large area is needed when the CT shows a perforated appendicitis.

Abdominal CT seems to reduce the rates of perforated appendicitis by eliminating unnecessary follow-up and time loss in some patients. However, the CT scanning did not change the rates of perforated appendicitis [1]. There is a concern that the use of CT may be an unnecessary waste of time and increase the rate of perforated appendicitis [14]. In our study, we found perforated appendicitis in a total of 16 patients (19.2%); As CT scanning is a quick procedure, requiring approximately 15 minutes in our hospital, we consider that this minimal time delay does not contribute to the development of perforation with appendicitis.

Some studies showed that false negative diagnosis of acute appendicitis by CT can lead to delayed surgical treatment [5]. In our study, 5 patients were operated upon according to clinical findings, although CT findings were negative for appendicitis. Histopathological evaluations confirmed acute appendicitis in 4 of these 5 patients.

Conclusion

The use of CT in suspicious appendicitis cases affected the surgeon’s diagnosis and treatment strategy in 98 (78.4%) cases and had no effect in 27 (21.6%) cases. The diagnosis was changed in 52% of patients and the treatment strategy in 26.4% of patients. We suggest that CT improved the judgment of the surgeons. This improvement is seen as more definitive diagnosis of appendicitis, avoidance of unnecessary surgery, or in modification of the incision.

Acknowledgement

We thank to Kristin Öztürk for helping English translation of this article.

Competing interests

The authors declare that they have no competing interests.

References

1. Hershko DD, Sroka G, Bahouth H, Ghersin E, Mahajna A, Krausz MM. The role of selective computed tomogrphy in the diagnosis and managment of suspected acute appendicitis. Am Surg 2002;68(11):1003-7.

2. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg 2001;136(5):556-62.

3. McGory ML, Zingmond DS, Nanayakkara D, Maggard MA, Ko CY. Negative appendectomy rate: influence of CT scans. Am Surg 2005;71:803-8.

4. Krajewski S, Brown J, Phang PT, Raval M, Brown CJ. Impact of computed tomography of the abdomen on clinical outcomes in patients with acute right lower quadrant pain: a meta-analysis. Can J Surg 2011;54(1):43-53.

5. Coursey CA, Nelson RC, Patel MB, Cochran C, Dodd LG, Delong DM, at al. Making the diagnosis of acute appendicitis: do more preoperative CT scans mean fewer negative appendectomies? A 10-year study. Radiology 2010;254(2):460-8.

6. Petrosyan M, Estrada J, Chan S, Somers S, Yacoub WN, Kelson RL, at al. CT scan in patients with suspected appendicitis: clinical implications for the acute care surgeon. Eur Surg Res 2008;40(2):211-9.

7. Schuler JG, Shortsleeve MJ, Goldenson RS, Perez-Rossello JM, Perlmutter RA, Thorsen A. Is there a role for abdominal computed tomographic scans in appendicitis? Arch Surg 1998;133:373-6.

8. Ege G, Akman H, Sahin A, Bugra D, Kuzucu K. Diagnostic value of unenhanced helical CT in adult patients with suspected acute appendicitis. Br J Radiol 2002;75(897);721-5.

9. Nathan RO, Blackmore CC, Jarvik JG. Therapeutic impact of CT of the appendix in a community hospital emergency department. AJR Am J Roentgenol 2008;191(4):1102-5.

10. Tsushima Y, Yamada S, Aoki J, Motojima T, Endo K. Effect of contrast-enhanced computed tomography on diagnosis and management of acute abdomen in adults. Clin Radiol 2002;57(6):507-13.

11. Santos DA, Manunga J Jr, Hohman D, Avik E, Taylor EW. How often does computed tomography change the managment of acute appendicitis? Am Surg 2009; 75(10):918-21.

12. Siewert B, Raptopoulos V, Mueller MF, Rosen MP, Steer M. Impact of CT on diagnosis and management of acute abdomen in patients initially treated without surgery. AJR Am J Roentgenol 1997;168(1):173-8.

13. Rao PM, Rhea JT, Novelline RA, Mostafavi AA, McCabe CC. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Engl J Med 1998 15;338(3):141-6.

14. Musunuru S, Chen H, Rikkers LF, Weber SM. Computed tomography in the diagnosis of acute appendicitis: definitive or detrimental? J Gastrointest Surg 2007;11(11)1417-21.

15. İnan, N Arslan A. Primary Epiploic Appendagitis: CT Findings: Case Report. Turkiye Klinikleri J Gastroenterohepatol 2010;17(2):115-7.

16. Akgün V, Sağlam M, Örs F, Battal B, Öztürk E, Şimşek A. Acute Epiploic Appendagitis: Tissue Harmonic Ultrasonography and Computed Tomography Imaging Features in Two Cases. Turkiye Klinikleri J Med Sci 2010;30(5):1716-9.

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Alaattin Ozturk, Hakan Bozkurtoglu, Yesim Uckurt, Cengiz Kaya, Zuhal Demirhan Yananli, Omer Faruk Akinci. The Effect of Computed Tomography on Surgeons Decisions in Suspected Appendicitis Cases. J Clin Anal Med. 2015;6(6):716-719

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Clozapine Therapy for Long-Term Prophylaxis in Bipolar Patients; Prescription Rates and Efficacy

Tonguç Demir Berkol 1, İlker Özyıldırım 2, Sibel Çakır 3, Olcay Yazıcı 3

1 Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Ankara, 2 Ünye Devlet Hastanesi, Ordu, 3 İstanbul Üniversitesi İstanbul Tıp Fakültesi Psikiyatri Birimi, İstanbul, Türkiye

DOI: 10.4328/JCAM.2373 Received: 27.02.2014 Accepted: 26.03.2014 Published Online: 27.03.2014

Corresponding Author: Tonguç Demir Berkol, Dodurga Mahallesi, Özdebirlik Sitesi, Ada:103 16/A, 06810, Türkkonut, Çayyolu, Yenimahalle, Ankara, Türkiye. T.: +90 3125962000 F.: +90 3123186690 E-Mail: tberkol@gmail.com

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Aim: It is reported that clozapine maintenance treatment could be effective in treatment-resistant bipolar patients. The aim of this study is to evaluate the prescription rates of clozapine, features of patients on clozapine prophylaxis and efficacy of clozapine prophylaxis in patients with bipolar disorder. Mate-rial and Method: 280 patients with DSM-IV diagnostic criteria for bipolar disorder, type I were included in the study. The patients’ medical records and life-charts were reviewed retrospectively and patients who took clozapine for maintenance treatment for at least one year were identified. Results: Twelve of 280 patients (4.8 %) took clozapine for prophylaxis for at least one period during lifetime. Among them 7 patients have only received clozapine, while 5 patients have used combination of clozapine and valproic acid. All of these twelve patients had resistance to at least two different maintenance treat-ments before clozapine prophylaxis. However, positive results were observed in all of the patients with clozapine prophylaxis. Discussion: These findings suggest that clozapine is regarded as an effective prophylactic choice for treatment of resistant patients with bipolar disorder. Consequently, this study demonstrates effectiveness and safety of clozapine use even in severe patients refractory to various strategies of prophylaxis. Retrospective na-ture of our study constitutes a limitation. However, when considering limited number of studies on this subject, it may still have a significant contribution. But more comprehensive prospective controlled studies are still needed.

Keywords: Bipolar Disorder; Clozapine; Prophlaxis

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Introduction

Studies evaluating prophylactic treatments in bipolar patients have shown that recurrences and chronic signs are common in these cases [1]. Despite various options with accepted effectiveness, resistant patients with inadequate response to long-term prophylactic treatment are common. For instance 30-40% of the patients are reported to be non-responsive to lithium, which is still gold standard in prophylactic treatment of bipolar disorder (BD) [2, 3].

Studies demonstrating effectiveness of clozapine, an antipsychotic drug, especially in resistant bipolar patients for prophylaxis were reported [4, 5, 6, 7, 8, 9, 10, 11]. However, they are limited to open-labeled studies with small sample sizes or case reports [12, 13]. In a review study, success of maintenance strategies comprising clozapine was reported in almost 70% of the patients [12]. In the only randomized controlled study assessed treatment resistant patients diagnosed with schizoaffective disorder and bipolar disorder in the one year fallow up period it was reported that in the end of a one-year follow up period. 13 patients whose treatment included clozapine in addition to their routine treatment had more positive results than those patients whose treatment did not include clozapine [11]. Retrospective evaluation of 17 bipolar patients receiving mood stabilizer and clozapine combination in a study conducted in Turkey revealed that all patients benefited from this approach [14]

In this study we aimed to assess the prescription rates of clozapine, features of patients on clozapine prophylaxis (CP) and efficacy of CP.

Material and Method

Study sample and psychiatric diagnosis

This study was conducted in Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry. The life charts of 280 patients with BD type I, who have been followed up in Istanbul Faculty of Medicine, Psychiatry Department, Mood Disorders Unit were evaluated retrospectively. The diagnoses of patients were evaluated by at least two experienced physicians according to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [15]. The psychiatric history, treatments and treatment responses are collected from patients, family members with detailed interviews and collateral hospital records. The patients are followed with mood charts and all clinical changes are recorded in every visit so all clinical data is updated regularly to create an optimum life chart. All participants gave a written informed consent and the Local Ethics Committee approval was obtained for the study.

Inclusion criteria and comparison groups

a) The patients older than 18 who met DSM-IV criteria for BD type-I were included in the study.

b) The patients who had at least one year CP were assigned for the determination of clozapine frequency (clozapine group).

c) The clinical features of patients who had CP were collected and compared with the features of patients who had no CP (non-clozapine group).

Maintenance treatment response

The efficacy of CP was determined with ‘mirror design’ method [16]. Zero point was indicated to be the time when maintenance treatment has started and maintenance treatment period was compared with the same duration of drug-free period prior to zero point. In order to determine response forms of patients with multiple drugs maintenance treatment period, their maintenance treatment periods were compared with the same duration of drug-free period prior to treatment.

Clinical evaluations of patients were transferred to a mood chart. Another follow-up scale is not used in this process.

According to their response features;

a) The treatment responder patients were described as those who never had any recurrence (good response) or those who had a recurrence during maintenance treatment period with a decrease in severity, period and frequency (moderate response) compared to the same period prior to maintenance treatment.

b) The treatment non-responder patients were described as those who had a recurrence during maintenance treatment period similar or even worse in severity, period and frequency in regard to the same period prior to maintenance treatment (poor response). Minimum duration for the maintenance treatment was 1 year. However, shorter durations were included if a clear conclusion can be made according to the mirror design when treatment changed earlier because of recurrences.

Side effects

Side effects were collected by a special section that belongs to side effects and adverse events in mood charts and reports of physicians in every visit retrospectively.

Statistical analysis

Statistical analyses were conducted by Statistical Package for Social Sciences (SPSS)-Version 11. Fisher exact test, independent sample t-test and Chi square were used for statistical analyses. Point for statistical significance was p< 0.05 and confidence interval was assumed to be 95%.

 Results

Frequency of prophylactic treatment prescription that includes Clozapine Twelve of 280 patients (4.8 %) took clozapine for prophylaxis for at least one period during lifetime. Among them 7 patients have only received clozapine, while 5 patients have used combination of clozapine and valproic acid (VA).

Sociodemographic and clinical variables

Mean age of clozapine treated patients was 46 (28-65) with seven females and five males. Severe and manic episodes were predominant in eleven patients (%91.7). All patients have been hospitalized at least once. Psychotic signs have been observed during at least one episode in all of them and 9 patients have experienced psychotic signs during more than half of the episodes (Table 1).

Other maintenance treatments before clozapine prophylaxis

Nine patients received lithium, eight patients VA and two patients received antipsychotic (AP) monotherapy as prophylaxis prior to CP. Moreover, seven patients have used lithium and VA, four patients have used lithium and AP, one patient VA and AP (other than clozapine) and three patients have received VA and AP combination treatment. Rationale for initiating clozapine was; inadequate response to prophylactic treatment in 11 patients, and inadequate response and treatment necessity for tardive dyskinesia (TD) in one patient. One patient has received five, two patients have received four, three patients have received three and the remaining six patients have used two different prophylactic treatments before CP.

Responsiveness to maintenance with Clozapine

All clozapine group patients have responded to clozapine comprising prophylaxis strategies. When considered in detail, no recurrence (good response) was observed in six of seven patients who have used clozapine monotherapy and in one of five patients receiving VA and clozapine (totally good response in 7 of 12 patients). In other five trials of CP, frequency and severity were significantly decreased compared to drug-free period despite recurrences (moderate response). Manic episodes occurred once in five patients who experienced recurrence. Depressive recurrence was also occurred in two of these patients during clozapine treatment. When depressive episodes were separately evaluated according mirror image, it was found that all patients except one were benefited from clopazine treatment.

Average clozapine doses, duration of maintenance that includes clozapine and side effects

Mean clozapine dosage was 256 mg/day (min.75 – max.600 mg/day) and mean duration of use was 41.0 months (min.12 – max.96 months). No serious side effect, such as TD, agranulocytosis and seizures, was observed. Patients with pre-treatment TD were benefited from clozapine treatment.

Discussion

12 of 280 BD-I patients have used a prophylactic treatment of clozapine for at least one year. Good results have been achieved in all patients and this is consistent with previous studies reporting high rates of positive results [7, 9, 11]. In spite of these positive results, clozapine is prescribed only if other maintenance strategies fail because of its some serious side effects such as agranulocytosis. Therefore, starting age of clozapine maintenance treatment is relatively old. Negative responsiveness of patients to various strategies before CP indicates the necessity of considering clozapine more frequently especially in refractory cases.

When clozapine users were compared with other patients, it was seen that episodes were more severe, and total number of previous manic episodes and hospitalizations were higher. Although it did not reach significant level, they displayed higher levels of psychotic signs (p=0.075) and experienced more episodes (p=0.067). These findings indicate that those clozapine treatments are used in more severe BD cases and explain why they are refractory to first line prophylactic strategies (such as lithium and valproate).

Bipolar patients are considered to be susceptible to the side effect of TD occurring with typical antipsychotic drug use [17]. No patients experienced TD during clozapine treatment in our study; conversely a patient with TD was benefited from clozapine treatment. This activity supports various reports suggesting potential effectiveness of clozapine in TD treatment [18, 19]

Retrospective nature of our study constitutes a limitation. However, when considering limited number of studies on this subject, it may still have a significant contribution. In a review of studies evaluating clozapine prophylaxis, mean duration of clozapine use was found to be 18.2 months [12]. Mean duration of 41.0 months achieved in our study is a substantially long period of time when compared to other studies and offers an opportunity to evaluate effectiveness of clozapine in longer prophylaxis treatments and is an advantage of our study.

Consequently, this study suggests effectiveness and safety of clozapine use even in severe patient’s refractory to various strategies of prophylaxis. But more comprehensive prospective controlled studies are still needed.

Competing interests

The authors declare that they have no competing interests.

References

1. Judd JL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002;59:530-7.

2. Goldberg JF, Harrow M, Leon AC. Lithium treatment of bipolar affective disorders under naturalistic followup conditions. Psychopharmacol Bull 1996;32:47-54.

3. Hartong EG, Moleman P, Hoogduin CA, Broekman TG, Nolen WA. Prophylactic efficacy of lithium versus carbamazepine in treatment-naive bipolar patients. J Clin Psychiatry 2003;64(2):144-51.

4. Hummel B, Dittmann S, Forsthoff A, Matzner N, Amann B, Grunze H. Clozapine as Add-On Medication in the Maintenance Treatment of Bipolar and Schizoaffective Disorders. Neuropsychobiology 2002;45(1):37–42.

5. Vacheron-Trystram MN, Braitman A, Cheref S, Auffray L. Antipsychotics in bipolar disorders. Encephale 2004;30(5):417-24.

6. Kusumakar V. Antidepressants and antipsychotics in the long-term treatment of bipolar disorder. The Journal of Clinical Psychiatry 2002;63(10):23-8.

7. Ciapparelli A, Dell’Osso L, Pini S, Chiavacci MC, Fenzi M, Cassano GB. Clozapine for treatment-refractory schizophrenia, schizoaffective disorder, and psychotic bipolar disorder: a 24-month naturalistic study. J Clin Psychiatry 2000;61:329-34.

8. Chen, Chin-Kang; Shiah, I-Shin; Yeh, Chin-Bin; Mao, Wei-Chung; Chang, Chuan. Combination Treatment of Clozapine and Topiramate in Resistant Rapid-Cycling Bipolar Disorder. Case Report, Clinical Neuropharmacology 2005;28:136–8.

9. Ciapparelli A, Dell’Osso L, Bandettini di Poggio A, Carmassi C, Cecconi D, Fenzi M et al. Clozapine in treatment-resistant patients with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder: a naturalistic 48-month follow-up study. The Journal of Clinical Psychiatry 2003; 64(4):451-8.

10. Poon SH, Sim K, Sum MY, Kuswanto CN, Baldessarini RJ. Evidence-based options for treatment-resistant adult bipolar disorder patients. Bipolar Disord 2012;14(6):573-84.

11. Suppes T, Webb A, Paul B, Carmody T, Kraemer H, Rush AJ. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment resistant illness and a history of mania. Am J Psychiatry 1999;156:1164-9.

12. Brambilla P, Barale F, Soares JC. Atypical antipsychotics and mood stabilization in bipolar disorder. Psychopharmacology 2003;166(4):315-32.

13. Gitlin M. Treatment-resistant bipolar disorder. Molecular Psychiatry 2006;11: 227-40.

14. Sertöz Ö, Akdeniz F, Vahip S. Clozapine treatment in bipolar and schizoaffective disorders: A retrospective study. Klinik Psikofarmakoloji Bülteni 2002;12(3):142-7.

15. American Psychiatric Association. DSM-IV – Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC: American Psychiatric Association; 1994.

16. Vieta E, Nieto E, Autet A, Rosa AR, Goikolea JM, Cruz N et al. A long-term prospective study on the outcome of bipolar patients treated with long-acting injectable risperidone. World J Biol Psychiatry 2008;9(3):219-24.

17. Gao K, Kemp D.E, Ganocy S.J, Gajwani P, Xia G, Calabrese R.J. Antipsychotic Inculded Extrapyramidal Side Effects in Bipolar Disorder and Schizophrenia. J Clin Psychopharmacol 2008;28(2):203–9.

18. Li CR, Chung YC, Park TW, Yang JC, Kim KW, Lee KH et al. Clozapine-induced tardive dyskinesia in schizophrenic patients taking clozapine as a first-line antipsychotic drug. World J Biol Psychiatry 2009; 10(4 Pt 3): 919-24.

19. Van Harten PN, Tenback DE. Tardive dyskinesia: clinical presentation and treatment. Int Rev Neurobiol 2011;98:187-210.

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Tonguc Demir Berkol, Ilker Ozyildirim, Sibel Cakir, Olcay Yazici. Clozapine Therapy for Long-Term Prophylaxis in Bipolar Patients; Prescription Rates and Efficacy. J Clin Anal Med. 2015;6(6):712-715

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Clinicopathologic Prognostic Factors in Locally Advanced Pancreatic Cancer Patients Treated with Radiation Therapy

Vildan Kaya 1, Aylin Fidan Korcum 2, Mustafa Yıldırım 3, Gamze Aksu 2, Beyza Şirin Özdemir 2, Ali Aydın Yavuz 2

1 Süleyman Demirel University School of Medicine, Department of Radiation Oncology, Isparta, 2 Akdeniz University School of Medicine, Department of Radiation Oncology, Antalya, 3 Ministry of Health Batman Regional Government Hospital, Department of Medical Oncology, Batman, Turkey

DOI: 10.4328/JCAM.2375 Received: 28.02.2014 Accepted: 26.03.2014 Published Online: 27.03.2014

Corresponding Author: Vildan Kaya, Süleyman Demirel University School of Medicine, Department of Radiation Oncology, 32260, Isparta, Turkey. GSM: +905334797408 F.: +90 2462112832 E-Mail: vildansimsir@yahoo.com

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Aim: The prognosis of pancreatic cancer is one of the worst malignancies. In randomized clinical trials done in recent times, the answer is researched for adjuvant chemotherapy, chemoradiotherapy. Our study investigated the clini-copathologic prognostic factors for pancreatic cancer. Material and Method: Patients diagnosed with histopathologically confirmed pancreatic cancer, followed by Akdeniz University School of Medicine, Department of Radia-tion Oncology between the years 2000-2008 were included in the study. Results: A total number of 32 patients were taken to the study. The tumor diameter values in predicting survival were analyzed using ROC (Receiver Operating Characteristics) curve analysis. Patients were grouped according to their tumor diameters: the tumor diameter lower than 4 cm (Group A), the tumor diameter higher than 4 cm (Group B). The mean survival of patients is determined as 17.3 months. The fact that there is whether or not lymph node involvement is found to be related with survival (p=0.009). A signifi-cant relationship between Group A and B in terms of survival is determined (p=0.029). Conclusions: While treatment is considered in patients who are planned to receive radiation therapy because of pancreatic cancer, the tu-mor diameter and the lymph node status should be taken into account as prognostic factors.

 

Keywords: Pancreatic Cancer; Radiation Therapy; Lymph Node Status; Tumor Diameter

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Introduction

The global pancreatic cancer ratio is approximately 8/100,000 person per year. It constitutes 2.2% of all the new cancer cases [1]. Men are more affected by this disease when compared to women (female: male ratio of about 1:1.5). The peak incidence is seen between the ages of 60-80 [2].

Despite the progress in surgical techniques, adjuvant chemotherapy and chemoradiotherapy, the pancreatic cancer is still one of the malignancies having worst prognosis. Just at the time of diagnosis, most of the patients are presented with a devastating disease, which is characterized by widespread tumor growth, vital organ dysfunction, uncontrollable pain, fast-growing cachexia and coagulopathy. Only 10-20% of the patients are suitable for surgery in the moment of diagnosis [3].

The pancreatic cancer has a low survival rate and surgical resection is still the only primary curative treatment. Recurrence is seen in 80% of the patients after surgery. Therefore, adjuvant combined therapy is a standard treatment after surgical resection in resectable pancreatic cancers [4]. In randomized clinical studies published in recent years, the answer is researched for adjuvant chemotherapy (CT), for adjuvant chemoradiotherapy or for surgery alone [5-7]. However, a consensus has still been not obtained on the optimal adjuvant treatment. The prognostic and/or the predictive clinicopathologic factors that will determine the benefit of the adjuvant treatment in these patients are also not well-defined [8-10].

Prognostic factors in patients with pancreatic cancer who receive adjuvant, definitive and palliative radiotherapy (RT) in our clinic are researched in this study.

Material and Method

Selection of patients

Pancreatic cancer patients who received radiotherapy in the Akdeniz University Department of Radiation Oncology between years 2000-2008 were evaluated. Tumor staging of patients was done according to the AJCC 7th edition criteria. A retrospective analysis of patients’ files is accomplished and the demographical data (age, gender), tumoral lesion in the pancreas (head, neck, and tail), pathological features (tumor diameter, histological grade, nodal status, metastatic status) and information on the received treatment are obtained. Informed consents of all patients who participated the study are taken for the treatment.

Patients who fulfilled following criteria are included in the study: patients between ages of 18-80, whose staging studies are accomplished with imaging methods (ultrasonography, abdominal computerized tomography, magnetic resonance imaging) before the treatment and patients whose Eastern Cooperative Oncology Group (ECOG) performance score is between 0 and 1. The exclusion criterion was ECOG > 2. Patients were categorized according to their age; >65 and ≤ 65.

 Radiation Therapy

A total of 45 Gy is applied with a Linear Accelerator device, by using 6-25 MV photon energy tumor bed in the classic box (AP-PA-Right Left lateral) area, 5 days a week with a fraction dose of 1.8 Gy. In addition to the tumor, tumor bed and regional lymphatic’s, and volumes of the organs at risk (OAR) are also determined in the radiotherapy planning. The OAR described as liver, kidneys, spinal cord and small intestines. The doses of the OAR during entire treatment process are calculated and the treatment plans of the patients who do not exceed the tolerance dose are approved. Toxicities are evaluated according to RTOG (Radiation Therapy Oncology Group) criteria in weekly examinations.

 Statistical Analysis

The statistical analyses are done by using the software program SPSS 15.0. By using the Chi-Square or Fisher test (in cases in which the values observed in cells do not satisfy the assumptions of the Chi-Square test), it is investigated whether there is a difference or not between patient groups in terms of gender, preoperative chemotherapy, operation type and taking simultaneous chemotherapy.

The tumor diameter values in predicting survival were analyzed using ROC (Receiver Operating Characteristics) curve analysis. According to result of this analysis, patients were grouped according to their tumor diameters: the tumor diameter ≤ 4 cm (Group A), the tumor diameter >4 cm (Group B).

The effects of the age (≤ 65 and >65) and gender of the patient’s, tumor localization (head, body and tail), tumor invasion (T1 to T4), lymph node involvement (negative or positive), perineural invasion (negative or positive), and tumor grade (grade 1-3) and tumor diameter (≤4 cm and >4 cm) on the survival are investigated by using the log rank test. The survival rates are calculated by using the Kaplan-Meier survival analysis. The cases under 5% of the Type 1 error level are accepted as statistically significant.

Results

A total number of 32 patients, of which 18 (56.3%) are men and 14 (43.7%) are women, were taken to study. The average age of the patients was 59.4±11 (range 35-79). The first symptoms in the submission of the patients were stomach pain and loss of weight in 21 (68.6%) patients, icterus in 10 (31.3%) patients and a new diagnosis of diabetes in one (3.1%) patient.

The tumoral lesion was in the head of the pancreas in 23 (71.9%) patients, in the body in 3 (9.4%) patients, in the tail in 1 (3.1%) patient and it was dispersed in the pancreas in 5 (15.6%) patients. Fourteen (43.8%) of the patients were operated and 18 (56.2%) patients were qualified as inoperable. Among the patients who were operated, 6 were operated through palliative surgery and 8 received Whipple operation.

Eighty-one point five percent of the histopathological samples had adenocarcinoma histology. The disease is identified in stage I for 1 (3.1%) of the patients, in stage II for 2 (6.3%) of the patients, in stage III for 21 (65.6%) of the patients and in stage IV for 8 (25%) of the patients. All metastatic patients had liver metastasis. The tumor grade was identified in 15 of the patients and tumors were well-differentiated in 1 (6.2%) of the patients, moderately differentiated in 8 (50%) of the patients, poorly differentiated in 3 (18.8%) of the patients and tumor showing neuroendocrine differentiation in 2 (13.4%) of the patients were determined.

Perineural invasion is identified in a ratio of 17.9% in the histopathological examination. The tumor was T1 for 1 (3.1%) of the patients, T2 for 2 (6.3%) of the patients, T3 for 5 (15.6%) of the patients and T4 for 24 (75%) of the patients. Lymph node metastasis is identified in 45.2% of the patients (Table 1).

The tumor diameter is determined as ≤4 cm for 17 (53.1%) of the patients (Group A) and >4 cm for 15 of the patients (Group B). There was no difference between Group A and B in terms of gender, age and tumor grade (p=0.755, p=0.863, p=0.338). There was no correlation between tumor size and location of the tumor in the pancreas (p=0.101). On the other hand, while the 88.2% of the tumors in Group A were in the head of the pancreas, this ratio was 53.3% in Group B. Distant metastasis is identified in one of the patients in Group A and in 7 of the patients in Group B.

The groups were different in terms of preoperative chemotherapy (p=0.005). Preoperative chemotherapy is applied to 17.6% of the patients in Group A and to 66.7% of the patients in Group B. Preoperative chemotherapy is applied to 13 (40.6%) patients among all. While 3 of applied chemotherapy regimens were 5-Fluorouracil based, 10 of them were Gemcitabine based. Simultaneous chemotherapy is applied to 22 (71%) of the patients. All of the simultaneous chemotherapy regimens were 5-Fluorouracil based regimens.

The mean survival of patients is identified as 17.3 months (%95confidence interval 10.2-24.4). The overall survival of patients is determined as 12.5% for 2 years, 9.4% for 3 years and 6.3% for 5 years (Figure 1).

No effect on the overall survival is identified for gender, age, tumor localization in the pancreas, perineural invasion and tumor grade in the survival analysis with one variable (p=0.887, p=0.692, p=0,912, p=0.568, p=0.322). Whether there is lymph node involvement or not is found to be related with survival (p=0.009). While the median survival is identified as 22.7±8.6 (%95 confidence interval 5.8-39.6) months in patients with no lymph node involvement, the median survival in lymph node involvement is identified as 10.4± 2.4 (%95 confidence interval 5.8-15) months.

A significant relationship between Group A and B in terms of survival is determined (p=0.029) (Figure 2). While the median survival in Group A was 16.2±2.8 (%95 confidence interval 10.6-21.7) months, the median survival in Group B was 6±1.6 (%95 confidence interval 2.9-9.1) months.

Discussion

In our study, we showed that tumor diameter is >4 cm or ≤ 4 cm and the fact that there is lymph node involvement or not had prognostic importance in patients having RT implementation for pancreatic cancer.

Tumors lower than 2 cm are classified as T1 in the TNM classification of the pancreatic cancer. T1 tumors are accepted as small pancreatic cancer in many studies and it is shown that its prognosis is better [11-13]. However in our study, it is shown that the prognosis is better in patients having a tumor diameter lower than 4 cm. In the study ACOSOG Z05031, in which the adjuvant treatment is evaluated, the patients having a tumor diameter lower and higher than 3 cm are compared and a relationship between survival and tumor diameter is not determined, contrary to our study [14].

The vascular support of the tumor decreases as the tumor diameter increases. Abnormal vascular support in tumors is one of the important mechanisms in the development of hypoxia. Hypoxic cells are more resistant to both radiotherapy and chemotherapy. It is shown that the tumor is completely oxygenated in cases in which the tumor diameter is below 1 mm and that partial hypoxia may occur in bigger tumors [15].

Another reason why the prognosis of patients having small pancreatic cancer is better may be related to the fact that distant metastasis is less seen in these patients. While distant metastasis is identified in only one of the patients having a tumor diameter lower than 4 cm in our study, the primary focus was over 4 cm in other metastatic patients. Similar results were also obtained in studies in which the small pancreatic cancer was 2 cm and lower [11,15].

It is put forward that small pancreatic cancers are better differentiated tumors [16]. On the other hand, no difference is identified when the patients are grouped according to their tumor diameters in our study. The reason for that may be small number of patients and the fact that patients who treated with RT were included to our study. RT is not implemented in metastatic patients except palliative treatment might have caused patient selection bias.

The fact that the tumor grade is an important prognostic factor is shown in many studies [17-19]. However, no relationship is determined between the tumor grade and survival in our study. The reason for that may be the small number of stage IV patients among all the patients who are taken into the study because the prognostic effect of the tumor grade in stage IV patients is significant [20].

It is shown in many studies that lymph node involvement is a poor prognostic factor in pancreatic cancer [21-23]. Slidell et al. showed that; not only the number of lymph node, but also LNR (ratio of metastatic lymph nodes to total number of examined lymph nodes) may be releated with more directive for postoperative survival (24). However, Murakami et al. suggested that the number of metastatic lymph node is more potent prognostic factor than LNR in the 119 patients that pancreatectomy is applied (25). In our country, Büyükkaşık et al. showed that; wide surgical resection of gastric cancer, increased mortality especially over the age of 70, as well as in pancreatic cancer (26).

In another study, in which they examined prognostic factors in pancreatic cancer patients that received chemoradiotherapy, Moghanaki et al. showed that the nodal status and the T stage have prognostic importance [27]. Unlike from our study, they determined that the prognosis is better in patients lower than age of 60.

As a result, the most important limitation of our study is small number of patients; we think that tumor diameter and lymph node involvement should be taken into account as prognostic factors while treatment is considered in patients who are planned to receive radiotherapy because of pancreatic cancer.

 Acknowledgements

We have no financial interest or conflict of interest in association with this work. This manuscript has not been published previously and is not being considered for publication by another journal. All authors have read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

References

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7. Garofalo MC, Regine WF, Tan MT. On statistical reanalysis, the EORTC trial is a positive trial for adjuvant chemoradiation in pancreatic cancer. Ann Surg 2006;244(2):332-3.

8. Chang DK, Johns AL, Merrett ND, Gill AJ, Colvin EK, Scarlett CJ, et al. Margin clearance and outcome in resected pancreatic cancer. J Clin Oncol 2009;27(17):2855-62.

9. Fortner JG, Klimstra DS, Senie RT, Maclean BJ. Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy. Ann Surg 1996;223(2):147-53.

10. Geer RJ, Brennan MF. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg 1993;165(1):68-72.

11. Pongprasobchai S, Pannala R, Smyrk TC, Bamlet W, Pitchumoni S, Ougolkov A, et al. Long-term survival and prognostic indicators in small (<or=2 cm) pancreatic cancer. Pancreatology 2008;8(6):587-92.

12. Geer RJ, Brennan MF. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg 1993;165(1):68-72.

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14. Picozzi VJ, Abrams RA, Decker PA, Traverso W, O’Reilly EM, Greeno E, et al. Multicenter phase II trial of adjuvant therapy for resected pancreatic cancer using cisplatin, 5-fluorouracil, and interferon-alfa-2b-based chemoradiation: ACOSOG Trial Z05031. Ann Oncol 2011;22(2):348-54.

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Vildan Kaya, Aylin Fidan Korcum, Mustafa Yildirim, Gamze Aksu, Beyza Sirin Ozdemir, Ali Aydin Yavuz. Clinicopathologic Prognostic Factors in Locally Advanced Pancreatic Cancer Patients Treated with Radiation Therapy. J Clin Anal Med. 2015;6(6):707-711

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Should TAPSE Score be in the Forefront Following the Tricuspid Valve Replacement?

Erdal Simsek 1, Ufuk Tutun 1, Ayca Boyaci 2, Zafer Iscan 1, Aytac Caliskan 1, Levent Birincioglu 1, Ahmet Saritas 1, Mustafa Pac 1

1 Department of Cardiovascular Surgery, 2 Department of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey

DOI: 10.4328/JCAM.2385 Received: 07.03.2014 Accepted: 26.03.2014 Published Online: 27.03.2014

Corresponding Author: Erdal Simsek, Turkiye Yuksek Ihtisas Training and Research Hospital Department of Cardiovascular Surgery, Altindağ, Ankara, Turkey. GSM: +905323280217 E-Mail: erdaldr@yahoo.com

Abstract
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Abstract

Aim: Tricuspid valve diseases are generally affected from rheumatismal dis-eases and it emerges by regurgitation. In our study, we aimed to search both the situation and importance of Tricuspid Annular Plane Systolic Excursion (TAPSE) score during the follow-up of patients who had undergone tricuspid valve replacement. Material and Method: Between the years of 2011-2013, the patients who were done tricuspid valve replacement have been evalu-ated retrospectively. Our group was made up of re-operated patients and the ones that were operated for the first time. TAPSE score, clinical clas-sification of New York Heart Association (NYHA), Mean Pulmonary Artery Pressure (MPAP), ejection fractions, echocardiographic measure parameters were checked and their correlations with clinical conditions, were evaluated. Results: During the follow-up of these patients post operatively, functional capacity (before the operation 3.31±0.63; 1.83±0.83), TAPSE score (pre-op-eration 17.38±3.15mm; 12.53±4.8mm), MPAP (pre-operation 35,53±14,72 mmHg; 30.3±11.2 mmHg) values were evaluated. In the values of NYHA and MPAP, marked clinical improvement was detected in parallel with clinical situation; the decline in score of TAPSE was observed contrary to clinical and the other parameters. Discussion: Although the TAPSE score is important in defining the mortality and morbidity before the operation, we observed that it is no such of an importance in the follow-up of patients who had tricuspid valve replacement. We think that, for the follow-up of these patients who had tricuspid valve replacement, clinic condition and other parameters should be in the forefront, however the score should be evaluated in the background.

Keywords: Tricuspid Annular Plane Systolic Excursion; Right Ventricular Function; Tricuspid Incompetence; Echocardiography

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Introduction

Tricuspid heart valves are mainly affected by rheumatic illnesses and co-occur with mitral valve involvement. It is discernible that 62% of patients with mitral valve disease have functional tricuspid valve dysfunction. It is very rare that the stenosis is seen isolated and generally it is collocated with insufficiency.

Decrement of the afterload of right ventricle, functional tricuspid regurgitation (TR) and some improvement in right ventricule (RV) function occur in parallel with decrease of the pulmonary artery pressure although tricuspid valve is not intervened during mitral valve surgery. However, during mitral valve surgery, in that of necessary surgical intervention applied to tricuspid valve, it was reported that improvement of TR and RV functions are much better [1].

Such questions like; “When and how should tricuspid valve intervened? What are the factors conditioning the mortality and morbidity?” are still valid and under discussion today.

Due to RV’s anatomical and complex structure, it is quite hard to evaluate the ejection fraction in a non-invasive way. In detaining the RV systolic function, the acceleration during isovolumetric contraction, the right ventricle myocardial performance, the changes in ventricle fraction area, three dimensional right ventricle ejection fraction, tissue Doppler-derived tricuspid lateral annular systolic velocity (Tri S), Tricuspid Annular Plane Systolic Excursion (TAPSE) can be effectively used [2].

TAPSE is a scoring system which is measured with non-invasive doppler echocardiography and is used in determining right ventricle function. This scoring system has been found in a relation with mortality and bad fractional classification [3].

• The place of TAPSE score in evaluating the right ventricle functions in patients who had tricuspid valve replacement (TVR)

• Is TAPSE score efficient in evaluations and follow-ups of patients undergone TVR and does it show any correlation with patient’s clinic? We have searched for the answers to these questions.

Material and Method

In between the years January 2011-March 2013, in our clinic, thirteen patients undergone TVR operation were evaluated retrospectively and were included in our study. As routine TAPSE score was not followed before the year 2011, TVR operations done before that year were not taken into consideration. Our patient group that evaluated retrospectively is composed of the patients that were operated before due to rheumatismal valve disease (Aort and/or mitral) and the ones that will be operated for the first time. The operations were performed by inserting cross clamp with the accompany of right thoracotomy or else, median sternotomy with cardiopulmonary bypass. For TVR, bioprosthesis and mechanical heart valves were performed. None of the patients were applied tricuspid valve reconstruction. Post-operative inotropic agent needs, the duration of intensive care unit stays, discharging from hospital times, the presence of ascites during pre and post operation, functional capacity, cardiac rhythm, MPAP (mean pulmonary artery pressure), TAPSE score and ejection fractions (EF %) were observed and the patients were evaluated in terms of clinical and measurement parameters (Table 1). Different patients of early-middle-late periods were invited for controls at different times. TAPSE score of patients, MPAP and their functional capacities were evaluated in accordance with New York Heart Association (NYHA), moreover their effects on mortality and morbidity were surveyed. In addition, the correlation of TAPSE with other parameters and clinical conditions were examined.

Echocardiography

Doppler color echocardiography was performed using a GE Vivid 7 console. Right ventricular function was assessed using TAPSE measured by M-mode in the trans-apical four chamber view. Right ventricular systolic dysfunction was defined as TAPSE <15 mm.

Statistical analysis

The data were presented as mean and standard deviations, and percentage, where appropriate. Chi square test and paired-t test were used to compare the test values where necessary. Probability (p) values below 0.05 were considered significant. Confidence intervals (CI) were calculated at the 95% level.

Results

7.7% of our patients (n=13) who had gone under TVR operation were men (N=1, age=35 years) and 92.3% was women (N=12, mean age=56±8.76 years). 84.6% of the study patients who had 3rd degree (23.1%) and 4th degree (76.9%) tricuspid valve insufficiency had been operated before for various reasons; but 15.4% were made up of the ones who were going to have an operation for the first time (Figure 1A). Operations were performed with the approach of right thoracotomy (46.2%) or median sternotomy (53.8%). The preoperative diagnoses are described in figure 1A and the surgical operations types are shown in figure 1B. Mechanical heart valves were used in 38.5% and bioprosthetic valves were used in 61,5% of TVR. In all our patients, preoperation and postoperation rhythms were atrial fibrilation and no patient had an extra intervention on rhythm. Ascites was 92.3% before the operation and after the operation was 15.4%. Throughout follow-ups, pre and post operational presence of, NYHA classification, MPAP, EF and TAPSE scores were evaluated (Figure 2). TAPSE scores and MPAP values were measured in different patient groups who came for check-ups at different time levels. Their approximate stay in intensive care unit was 8.91±11.56 days. Only one patient became exitus (7.7%). While two of our patients still stay in our hospital for treatment, rest of the ten patients were released from the hospital in good health.

Discussion

Tricuspid heart valves are often affected by rheumatic diseases. There can be observed stenosis or regurgitation, however it mostly appears in regurgitation. In mitral valve disease, the geometry of right ventricle changes, papillar muscles relatively change places, the shape and size of tricuspid annulus change, causing functional tricuspid regurgitation.

During the five years of patient follow-ups, who were operated because of mitral insufficiency, it was observed serious tricuspid regurgitation and mortality amount was 50%, on the other hand, the ones with medium level insufficiency weren’t observed to have any mortality related to tricuspid valve. In our study, where tricuspid operation was done with fifteen patients series due to rheumatic causes, operative mortality was found as 20%. Within the same study, the half of survived patients were set to be in class III – IV according to NYHA functional classification. While in the study we prepared, our mortality rate was found as %7.7, in thirteen patients series, NYHA classification in survived patients was found as 3.31±0.63 before the operation and as 1.83±0.83 after the operation.

It was shown that functional tricuspid valve regurgitation decreased after mitral valve replacement (without insufficiency level before operation being considered). In the same study, it was shown that there was a bit of recession at first in the ones who are over grade 2, and in 3 years time, TR continued in Grade 2 and over [1]. It was observed that the recovery in TR was temporary. In the course of mitral valve intervention, effective tricuspid valve repair or replacement enable a permanent recovery [1]. In the group whose TR grade is between 0-1, RV function was normal and over grade 2 group degenerated RV function was determined. In time, insufficiency in tricuspid valve was progressing, deterioration the patient’s clinic [4]. Most part of the patients in our serial were made up of re-operated individuals whose tricuspid heart valves weren’t intervened during the first operation. Our results are concordant with literature. In the course of first operation, the risk of mortality and morbidity increased as a result of insufficient intervention to tricuspid heart valve, thus leading to a probability of patients who have the predicament of surgical operations.

Either in adult or congenital heart diseases; afterload, preload and contractility play an important role on right ventricle systolic performance [5]. The right ventricle systolic function is determined by; ventricle free wall movement, apical basal shortening during contractions and the movement of interventricular septum which develops as a connection of two ventricles. RV function is dependent on both ventricles so, it is harder to determine RV function non-invasively compared to the one on the left. Determining the systolic performance, non-invasive methods are more useful and practical than other invasive methods. Evaluating TAPSE score is easy, cheap and more advantageous owing to its repeatability.

Right ventricle dilatation determines mortality and morbidity and is of a very high-importance prognostic factor [3]. There was observed a strong correlation between right atrial pressure elevation and mortality [6,7].

For right heart disease; high pulmonary artery pressure, the presence of pericardial effusion, right atrial area index, right ventricular Tie index [8] and TAPSE [9] are the factors which determine the prognosis.

Pulmonary hypertension is a hemodynamic and pathophysiological clinic course which progress on average pulmonary artery pressure of 25mmHg and over [6]. In defining the mortality, the cut off value of PAP is 70 mmHg. PAP above 70 mmHg is significantly related with the renal and hepatic complications, prolonged mechanical support, pericardial effusion [3]. According to one study, it has been concluded that, there is no relationship between the ones having mitral valve disease with MPAP ≥ 50 mmHg and mortality after operation [10]. In the patients who are followed up for pulmonary artery hypertension and whose average pulmonary artery pressure are alike, TAPSE value of ≥2.0 cm have better prognosis than the ones with ≤2.0 cm. There is a negative correlation between TAPSE score and PAP. It was observed that the score decreases in patients with high PAP [11]. In our study, MPAP values decreased in post-operation follow ups and this has been parallel to clinical recovery. There hasn’t been observed any correlation between TAPSE score and MPAP due to problems about score measure, which will be discussed later in another argument.

There is a close relation between RV average TAPSE score and mortality and morbidity. In accordance with the study of TAPSE on age and body surface area (BSA), the score has a stronger relationship with age and a weaker relationship with BSA [12]. While it has been set that the score has reached its peak value at the age of 18, there has been detected no difference between sexes [12]. Tachycardia, high grade TR after operation, the wideness of left atrial systolic area, low left ventricle EF were found in relation with TAPSE’s value being low [1]. The very close relation of TAPSE score with right ventricle function was shown in studies done with radionuclide EF [13], magnetic resonance [14]. While the ones with average score 12.23 ± 4.83 mm had more mortality, in 18.49 ± 5.8 mm ones, there were seen meaningfully less [3]. TAPSE being <2.0cm shows that the left or right ventricle starts to lose its function, however >2.0cm value means ventricle function is normal. There has been observed very important difference within Intra-inter observers in measuring the TAPSE score [15]. It was shown that, for patients with TAPSE < 2cm, RV ejection fraction is <40% [16]. TAPSE is an essential definer for cardiac index. TAPSE being <1.3 cm shows 76% specificity and sensitivity for left ventricle EF decrease.

Related to left and right ventricle EF, there has been detected a crucial correlation between TAPSE and left ventricle dysfunction [17]. TAPSE score gives more important information and shows high sensitivity and specificity rather than RV systolic and diastolic function in terms of ventricle echocardiographic parameters [18]. It hasn’t been shown that the maximum velocity rate of tricuspid valve during early diastole and atrium contraction doesn’t define RV systolic and diastolic function, alone [19].

At the same time, maximum velocity rate of tricuspid valve was seen that it is relationship to left ventricle systolic and diastolic function [19]. It was pointed out that TAPSE score has a relationship with EF measured with echocardiography [20,21]. TAPSE score was found less effective in determining right ventricle functions in the group that was applied Mitrale valve replacement solely, than in the group applied TVR [1]. There are other studies as well which support that TAPSE score does not confirm its relevance in measuring RV function after the operation [22].

There has been observed a meaningful decrease in TAPSE score during TVR follow ups among our patients. Although there has been a very important clinic recovery during late period follow ups, it was observed that TAPSE score had increased most to the pre-operation value. Clinical recovery, loss of ascite, the precious decrease in the score despite advanced recovery in functional classification remind us of the relation between valve ring occupancy within TVR operated patients. By the reason of restriction within after-TVR mechanic and bioprosthesis valve ring’s annulus movements, TAPSE score was found low, which has no correlation between patient’s clinic and NYHA functional classification. Even though there has been a clinic recovery in all our patients, detection of decrease in TAPSE score confirms this very idea of ours. While in TVR planned patients, pre-operation TAPSE score defines mortality and morbidity during the course of post-operative follow ups, functional classification, clinic parameters and MPAP stand in the front.

The recovery in right ventricle after the intervention on tricuspid valve increases slowly in the course of time and become permanent. The acceleration in TAPSE score during early period after TVR (good prognosis) is not very clear. Among the ones with functional TR secondary to mitral valve disease, the decompositions in RV right after TVR have been recovery quite fast, however, this hasn’t reflected on TAPSE score.

Either in congenital or right ventricle related mature heart diseases, it has become more of an issue to present right ventricle functions in a quantitative way. TAPSE value right ventricle function is an important parameter that determines cardiac index. Among the group undergone TVR, TAPSE score is low due to the restrictions in the annulus movements related to valve in the early period and this disables us to no observe clinical condition, mortality and morbidity. We consider that in evaluating cardiac functions among the TVR done patients, of course clinical and other parameters should be more in the front.

The Restrictions of the Study

The importance of TAPSE score in determining the right ventricle function has been lately discovered. For that reason, the number of patients has been less as the score is being considered for such a short period of time. The patients were invited for follow ups at different times and their scores were measured. In order to measure and evaluate their TAPSE scores, some patients were invited at early period while others were called out during middle and late periods. Our aim for the future is to homogenize our patients’ follow up durations and to better introduce the efficiency of TAPSE score on TVR applied patients’ follow ups. For this reason, newly TVR applied patients and TAPSE scores have been added in the group. We would like to share our early period results with you.

Conflict of interest

The Authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. 

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22. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23 (7): 685-713.

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Erdal Simsek, Ufuk Tutun, Ayca Boyaci, Zafer Iscan, Aytac Caliskan, Levent Birincioglu, Ahmet Sarıtaş, Mustafa Pac. Should TAPSE Score be in the Forefront Following the Tricuspid Valve Replacement?. J Clin Anal Med. 2015;6(6):702-706

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The Evaluation of Thyroid Function Disorders in Patients with Allergic Rhinitis

Ayşe Neslin Akkoca 1, Gül Soylu Özler 2, Seçil Günher Arıca 3

1 Mustafa Kemal Üniversitesi, Tıp Fakültesi Eğitim ve Araştırma Hastanesi, Aile Hekimliği Anabilim Dalı, Hatay, 2 Mustafa Kemal Üniversitesi Tıp Fakültesi Eğitim ve Araştırma Hastanesi, Kulak Burun Boğaz Anabilim Dalı, Hatay, 3 İstanbul Okmeydanı Eğitim ve Araştırma Hastanesi, Aile Hekimliği Kliniği, İstanbul, Türkiye

DOI: 10.4328/JCAM.2381 Received: 04.03.2014 Accepted: 17.03.2014 Published Online: 21.03.2014

Corresponding Author: Gül Soylu Özler, Mustafa Kemal Üniversitesi Tayfur Ata Sökmen Tıp Fakültesi, Kulak Burun Boğaz Anabilim Dalı, Hatay, Türkiye. GSM: +905053980778 E-Mail: soylugul@yahoo.com

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Abstract

Aim: In this study, we aimed to determine the ratio of thyroid hormone disorders in subjects with allergic rhinitis and investigate the association between these two diseases. Material and Method: 62 patients who pre-sented with symptoms of allergic rhinitis and have positive skin prick test and 62 patients as a control group were included in the study to examine thyroid hormone disorders. Results: Mean age of patients with allergic rhi-nitis were 43.20 ± 18.55. 54.4% of the patients were females and 45.6% of the patients were males. Thyroid hormone results were; 2.33 ± 1.69 for FT3, 2.40 ± 1.96 for FT4, 4.49 ± 3.61 for TSH. Subclinical hyperthyroidism, euthyroidism,subclinical hypothyroidism and clinical hypothyroidism were detected in 4.8%, 61.4 %,29% and 4.8% of patients,respectively. Mean age of patients with allergic rhinitis were 40.03 ± 17.7. 55% of the patients were females and 45% of the patients were males. Thyroid hormone results were; 2 , 21 ± 1.45 for FT3, 2 , 40 ± 1.81 for FT4, 4. 22 ± 4.37 for TSH. Subclinical hyperthyroidism, euthyroidism,subclinical hypothyroidism and clinical hypothyroidism were detected in 9.5%, 68.3 %,12.7% and 9.5% of patients,respectively. There was no difference between patient and control groups in terms of hypothyroidism, euthyroidism and hyperthyroidism (p = 0.35). There was no difference between genders in terms of hypothyroidism, euthyroidism and hyperthyroidism(p = 0.40). Discussion: No deterioration in thyroid functions were found in patients with symptoms of allergicrhinitis.

Keywords: Allergic Rhinitis; Skin Prick Tests; Hypothyroidism

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Giriş

Alerji her yaş grubunda görülebilen, toplumun yaklaşık beşte birini etkileyen önemli bir hastalıktır [1]. En sık görülen alerjik hastalıklar;astım, rinit, anaflaksi, besin ve böcek alerjileri,egzama ve ürtikerdir. Daha nadir olmakla birlikte otoimmün tiroid hastalığı, cinsel fonksiyon bozukluğu, uyku bozuklukları da alerjik hastalıklarla birliktelik gösterebilmektedir [2,3].Baskılayıcı T hücre defektinin hem atopik sendrom hem de otoimmün tiroid hastalığına sebep olduğu düşünülmektedir[4]. Alerjik hastalıklardan alerjik rinit (AR) ile tiroid hastalıklarının birlikteliğini bildiren az sayıda çalışma vardır [5,6]. Literatürlerde tiroid hastalığı olanlarda artmış kronik ürtiker insidansı da bildirilmesine rağmen, bu hastaların deri prick testi sonuçları ile ilgili yeterli veri yoktur [7].

Rinitler yaygın olarak alerjik, enfeksiyöz ve alerjik ve enfeksiyöz olmayan olarak üç grupta incelenir [8].Hormonal rinitler alerjik ve enfeksiyöz olmayan rinitler içinde incelenmektedir. Hormonal rinit nedenleri olarak hipotiroidizm, gebelik, puberte,akromegali, oral kontraseptif kullanımı kabul edilmektedir [9].Hipotiroidizm, tiroid glandın organizmadaki fonksiyonel etkisinin ortadan kalkması sonucu görülen bir klinik tablodur.Hipotiroidili hastalarda klinik tablo tüm vücut sistemlerini etkilediği gibi, kulak burun boğaz bölgesinde de klinik değişikliklere neden olur.Hipotiroidizmdeki nazal semptomlar, hastalığın edinsel durumuyla birlikte görülür. Literatürde bu konuda az sayıda çalışma vardır. Bu çalışmalarda, hipotiroidizmde nazal submukozada histolojikve fizyolojik değişiklikler saptanmıştır [10].Burun tıkanıklığı ve rinore, hipotiroidili kişilerdeen sık görülen rinit semptomlardır [11].

Bu çalışmanın amacı, hipotiroidizm ve rinitler arasında öne sürülen ilişkiyi irdelemektir. Bu çalışma ile allerjik rinit tanısı konulmuş olan hastalarda tiroid fonksiyon bozuklukları olup olmadığını göstermeyi amaçladık.

Gereç ve Yöntem

Çalışma grubu ve Çalışma planı

Bu çalışma Mustafa Kemal Üniversitesi KBB ve Aile Hekimliği Anabilim Dallarının işbirliği ile etik kurul onayı alınarak gerçekleştirildi. Çalışmaya, kliniğimizde alerjik rinit tanısı alan ve deri prick testi yapılmış olan 62 erişkin hasta (yaş ortalaması 41,6±18,14; %54,8’ü kadın, E %45,2’si erkek) ile 62 hastadan oluşan kontrol grubu (yaş ortalaması 40,03±17,7;%61’i kadın, %39’u erkek) tiroid hormon bozuklukları yönünden incelenmek üzere çalışmaya dâhil edildi. Hastalara bilgi verilerek, yazılı izinleri alındı.

Laboratuvar Değerlendirmesi

Hastaların tiroid hormon testleri (T3,T4,TSH) istendi. Normal serum değerleri hastane biyokimya laboratuvarı ölçümlerine uygun olarak TSH=0.27-4.2 mIU/lt, FT3 = 1.8-4.6 pg/ml, FT4 = 0.93-1.7 ng/dl arasında normal kabul edildi.

TSH’nın 10 mIU/lt üzerinde olduğu olgular klinik hipotiroidi, 10 mIU/lt altında olduğu olgular subklinik hipotiroidi, TSH sı 0,25 altında olan olgular ise hipertiroidi olarak kabul edildi. Tüm olguların 10-12 saatlik açlıktan sonra sabah 08.00-08.30 arasında biyokimyasal tetkikler için venöz kan örnekleri alındı. Daha önce tiroid hastalığı tanısı almış olan ve bu nedenle ilaç kullanan hastalar çalışma dışı bırakıldı.

İstatistiksel analiz

Verilerin tanımlayıcı istatistiklerinde ortalama, standart sapma, medyan, min-maks, oranları, frekans değerleri kullanılmıştır. Verilerin dağılımına Kolmogorov Simirnov testi ile bakılmıştır. Niceliksel verilerin analizinde bağımsız örneklem t testi kullanılmıştır. Niteliksel verilerin analizinde Ki-kare testi kullanılmıştır. Analizlerde SPSS 15.0 programı kullanılmıştır.

Bulgular

Demografik data

Deri prick testi pozitif bulunan 62 alerjik rinit hastasının ve 62 kontrol grubu hastanın cinsiyetleri açışından farklılık bulunamadı(p=0,9).Grupların yaş ve tiroid hormon düzeyleri karşılaştırılması ise Tablo 1’de görülmektedir.

Hasta grubunda; Sublinik hipertiroidi’si olanlar %4,8 oranında bulundu. Ötiroid olanlar %61,4, subklinik hipotiroidisi olanlar %29 ve klinik hipotiroidisi olanlar %4,8 oranında bulundu. Kontrol grubunda ise; sublinik hipertiroidisi olanlar %9,5;ötiroid olanlar %68,3;subklinik hipotiroidisi olanlar %12,7 hipotiroidisi olanlar %9,5 oranında bulundu(Tablo 2).

Hasta ve kontrol grubunda hipotiroidizm, ötiroidizm ve hipertiroidizm açısından fark bulunamadı(p=0,35).

Tartışma

Alerjik rinit en sık görülen kronik hastalıklardan biridir. Tüm doktor ziyaretlerinin en az %2,5’undan sorumludur [12].Toplumdaki insidansının %10 ile %25 arasında olduğu tahmin edilmektedir[13]. Türkiye’de sıklığı % 11-17,6 arasında bildirilmektedir.

Rinit tanısı, günde bir saatten fazla süren burun tıkanıklığı, burun kaşıntısı, hapşırma ve koku almada azalmayı kapsayan nazal semptomlardan ikisinin olması ile konulur [14,15]. Epidemiyolojik çalışmalarda, kronik rinitli olguların yaklaşık %50’sinin alerjik kökenli olduğu saptanmıştır [16,17].Epidemiyolojik çalışmaları güçleştiren bir başka durum da aynı olguda alerjik olmayan rinit ile alerjik rinitin birlikteliğidir. Yapılan bir çalışmada saf alerjik rinit %43, saf alerjik olmayan rinit %23 ve ikisi birlikte %34 oranında bulunmuştur. Bu oranlar alerjik olmayan rinit prevalansının %57 olduğunu göstermektedir [17].

Tiroid hormonları, vücutta bütün hücrelerin gelişmesi ve normal çalışması için gerekli tüm biyolojik olaylar üzerinde direkt veya indirekt olarak etkilidirler. Hipotiroidizm, kulak burun boğaz bölgesinde de klinik olarak tanımlanabilen birtakım değişikliklere neden olur. Kulakta, işitme azlığı primer semptomdur [18].Literatürde, hipotiroidinin nazal yakınmalarada yol açabileceğini işaret eden az sayıda çalışma vardır [20,21].Literatürde hipotiroidizm tanısı konulan hastaların %2-3’ünde rinit tablosuna rastlanmaktadır [24].

Bizim çalışmamızda ise; sublinik hipertiroidi’si olanlar %4,8, ötiroid olanlar %61,4, subklinik hipotiroidi’si olanlar %29,hipotiroidi’si olanlar %4,8 oranında bulundu. Hipotiroid,ötiroid ve hipertiroidik hastalar arasında anlamlı bir ilişki bulunamadı(p=0,35).

Proud ve Lange [19] tarafından yapılan çalışmada, hipotiroidizme bağlı burun mukozasında oluşan değişiklikler tanımlanmıştır. Araştırmacılar, iki köpekte kısmi, sekiz köpekte total olmak üzere toplam 10 köpekte tiroidektomi ameliyatı yapmışlardır. Kısmi tiroidektomi yapılan iki köpeğin burun mukozaları, tiroidektominin 3.ve 6. haftalarında histopatolojik olarak incelenmiştir. Her iki hayvanın burun mukozasında hipertrofi ve silya kaybı saptanmıştır. Total tiroidektomi yapılan sekiz köpek, ameliyat sonrası birinci aydan bir yıla uzanan zaman aralıklarında öldürülmüş ve histopatolojik olarak incelenen burun mukozalarında hipertrofi, silya kaybı ve submukozal enflamatuvar hücre infiltrasyonu gözlenmiştir.

Sonuç olarak; bu çalışmada, çalışma ve kontrol grubu arasında anlamlı bir fark bulunmamakla birlikte tiroid fonksiyon bozukluklarının alerjik rinit ile ilişkisini araştırmak için daha büyük hasta gruplarında çalışmalara ihtiyaç vardır.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

1. Koca Kalkan İ, Kalpaklıoğlu AF, Dağlıoğlu A, Kılınçkaya MF. Allerji bilinen, tanınan ve yeterli tedavi edilen bir hastalık mı? Asthma Allergy Immunol 2011;9:131-7.

2. Gül Ü, Çakmak S, Gönül M, Soylu S, Kılıç A. Kronik ürtikerde tiroid fonksiyon testleri ve tiroid otoantikorları istenmeli mi? Asthma Allergy Immunnol 2009;7: 39-43.

3. Kirmaz C, Aydemir O, Bayrak P, Yuksel H, Ozenturk O,Degirmenci S. Sexual dysfunction in patients with allergic rhinoconjunctivitis. Ann Allergy Asthma Immunol 2005;95(6): 525-9.

4. Moens HJ, Wiersinga WM, Drexhage HA. Association between autoimmune thyroid disease, atopy, and urticaria? Lancet 1984;2(8402):582-3.

5. Günel C, Başak HS, Güney E. The relationship between hypothyroidism and rhinitis. Kulak BurunBogaz Ihtis Dergisi 2010;20(4):163-8.

6. Reisacher WR. Prevalence of autoimmune thyroid disease in chronic rhinitis. Ear Nose Throat J 2008;87(9):524-7.

7. Artantaş Ş, Gül Ü, Kılıç A, Güler S. Skin findings in thyroid diseases. Eur J Intern Med 2009 Mar;20(2):158-61

8. International Consensus Report on the diagnosis and management of rhinitis. International RhinitisManagement Working Group. Allergy 1994;49(19 Suppl):1-34.

9. Scadding GK. Non-allergic rhinitis: diagnosis and management. Curr Opin Allergy Clin Immunol 2001;1:15-20.

10. Black RR, Maxon HR. Bening disaeses of the thyroid gland. In: Richar Z, editor. Otolaryngology. 3rd ed.Philadelphia: W. B Saunders Company; 1991.p.2483-97.

11. Önerci M, Yücel T. Sistemik hastalıklarda nazal bulgular ve rinit. In: Önerci M, editor. Rinitler. Ankara:Kutsan Ofset; 1999. s. 151-60.

12.Spector SH, Bernstein IL, Li JT et al.Parameters forthe diagnosis and management of sinusitis. J Allergy Clin Immunol 1998; 102 (6Part 2): S107-S145.

13.Kucukoduk S,AydinM,Cetinkaya F, et al.The prevalence of asthma and other allergic diseasesin a provinve of Turkey. Turk J Pediatr 1996;38(2): 149-53

14. Lund V.Allergic rhinitis-making the correct diagnosis. Clin Exp Allergy 1998;28 Suppl 6:25-8.

15. Bachert C. Persistent rhinitis – allergic or nonallergic? Allergy 2004;59 Suppl 76:11-5

16. Druce HM. Chronic rhinitis. Allergy Proc 1990; 11:295-8.

17. Settipane RA, Lieberman P. Update on nonallergic rhinitis. Ann Allergy Asthma Immunol 2001;86:494-507

18. Ritter FN. The effects of hypothyroidism upon the ear, nose and throat. A clinical and experimental study. Laryngoscope 1967;77:1427-79

19. Proud GO, Lange RD. The effect of thyroidectomy on the nasal mucosa of experimental animals. Laryngoscope 1957;67:201-7

20. Ritter FN. The effects of hypothyroidism upon the ear, nose and throat. A clinical and experimental study. Laryngoscope 1967;77:1427-79.

21. Slebodzinski AB, Tratwal Z. Association of the early stage of the subclinical form of atrophic rhinitis with hypothyroidism in growing pigs. Br Vet J 1988; 144:395-402

22. Lund V.Allergic rhinitis-making the correct diagnosis. Clin Exp Allergy 1998;28 Suppl 6:25-8.

23. Bachert C. Persistent rhinitis – allergic or nonallergic? Allergy 2004;59 Suppl 76:11-5

24. Farrbaks DNF, Raphael GD. Nonallerjik rhinitis and infection. In: Cummings CW, Haughey BH, Thomas JR, editors. Cummings otolaryngoloy head and neck surgery. Volum I. 2nd ed. Philadelphia: Mosby; 2005. p. 775-85.

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Ayse Neslin Akkoca, Gul Soylu Ozler, Secil Gunher Arica. The Evaluation of Thyroid Function Disorders in Patients with Allergic Rhinitis. J Clin Anal Med. 2015;6(6):699-701

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Referral to the Hospital and Emergency Ambulance Service Uses Patterns of the Inmates and Convicts

Emine Öncü 1, Sümbüle Köksoy 2, Mehmet Ali Sungur 3

1 Mersin İMKB Anadolu Sağlık Meslek Lisesi, Mersin, 2 Mersin Üniversitesi Sağlık Yüksekokulu Hemşirelik Anabilim Dalı, Mersin, 3 Düzce Üniversitesi, Düzce Üniversitesi Tıp Fakültesi, Biyoistatistik Ve Tıbbi Bilişim AD, Düzce, Türkiye

DOI: 10.4328/JCAM.2355 Received: 23.02.2014 Accepted: 16.03.2014 Published Online: 17.03.2014

Corresponding Author: Emine Öncü, Mersin IMKB Anadolu Sağlık Meslek Lisesi 3 Ocak Mah. Cemal Paşa Caddesi No:1/C Mersin, Türkiye. GSM: +905052775502 E-Mail: eeoncu@gmail.com

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Abstract

Aim: The purpose of this study was to determine the reasons for referral to the hospital and 112 emergency ambulance service uses patterns of the inmates and convicts in an E type prison. Material and Method: In this de-scriptive study, it was evaluated the prison records associated with referral to the hospital and 112 emergency ambulance service uses for one year in 2010- 2011. Of the statistical analysis, descriptive statistics, chi-square test and Fisher’s Exact Test were used. Results: All inmates and convicts were man, the median of age was 30,0 (min 18- max 68) years and substance use was 34,5%. The number of prisoners were referred to the hospital 815, total referrals were 1491; (referrals ranged from one to six) and most common in January; and according to frequency, reasons of the referral were eyes problems, musculoskeletal disorders and psychological problems. Emergency medical service was used for in medical causes (78,3%), accident, trauma and injuries (16,4%), suicide (5,3%). Discussion: Findings from the study show that prisoners are more likely to have suffered physical and mental health problems that compared to the rest of society and have significantly high substance use rates.

Keywords: Prisoner Health; Referral Hospital; Emergency Medical Services; Ambulance

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Giriş

Tüm dünyada mahkûm sayısı 10 milyonu aşarken, geçen 10 yıllık süreçte artış bir buçuk milyon dolayındadır [1]. Türkiye’de ise tutuklu ve hükümlü sayısı 2000’li yıllardan bu yana yaklaşık 2,7 kat artarak 136 bine ulaşmıştır [2].

Hızla artan mahkûm sayısı ile birlikte azalan sosyal destek, cezaevlerinin uygunsuz fiziki koşulları, beslenme ve hijyen yetersizliği mahkûmların bu kurumlara getirdikleri sorunlarla birleşince çok ve çeşitli sağlık sorunlarına yol açabilmektedir [3,4]. İlgili literatür tarandığında başlıca sağlık sorunlarının mental hastalıklar, madde bağımlılığı ve bulaşıcı hastalıklarda yoğunlaştığı görülmektedir [5,6]. Toplumda sıklıkla görülen soğuk algınlığı, yaralanmalar, sırt ağrısı, migren, dermatit gibi akut sağlık problemleri, genel popülâsyondaki prevalansa benzer şekilde mahkûm grubu da etkilerken epilepsi, astım, iskemik kalp hastalıkları, diş problemleri ve enfeksiyon hastalıkları gibi sorunların yaygınlığı ise daha yüksektir. Genellikle toplumun yoksul kesiminden gelen bakım görmemiş, hastalıklarla, bağımlılıklarla ve aynı zamanda ruhsal sorunlarla cezaevine giren bu grupta kişilik bozukluğu, psikoz ve madde bağımlılığı gibi faktörler suça neden olan ya da suçla ilişkili olabilecek riskler olmasının yanında kendine zarar vermeye ve intihara da yol açabilmektedir [7,8].

Mahkûmların sağlık problemleri yelpazesinin oldukça geniş olduğu belirtilmesine karşın [6] ülkemizde mahkûmların sağlığına dönük çalışma sayısı oldukça sınırlıdır [9,10]. Tutuklu ve hükümlülerin hastaneye sevk ve acil sağlık hizmetleri kullanım nedenlerinin belirlenmesi amacıyla yapılan bu araştırmanın, cezaevinde yüksek prevelansa sahip hastalıkların ve sağlıkla ilgili sorunların önlenmesine dönük yapılacak çalışmalara ve ilgili literatüre katkı vermesi beklenmektedir.

Gereç ve Yöntem

Tanımlayıcı nitelikteki bu araştırmanın verileri, bir E Tipi Kapalı Ceza İnfaz Kurumu kayıtlarından retrospektif olarak elde edildi. Çalışma, Adalet Bakanlığı ve Mersin Üniversitesi Klinik Araştırmalar Etik Kurulu’ndan gerekli izinler alındıktan sonra, 01-30 Haziran 2011 tarihleri arasında gerçekleştirildi. Ceza infaz kurumunda elektronik ortamda ve elle tutulan kayıtlar üzerinden, Haziran 2010- Mayıs 2011 dönemindeki sevkler ile 112 acil çağrıları yaş, öğrenim, meslek, medeni durum, madde bağımlılığı, sevk/112 çağrı tarihleri, sayısı ve nedenleri açısından değerlendirildi. Çalışma evreni olarak cezaevinin tercih edilmesinin nedeni son yıllarda sayıları hızla artan tutuklu/ hükümlülerin sınırlı kapasiteye sahip cezaevlerinde daha çok ve ciddiyeti artan sağlık sorunları ile karşı karşıya olabileceklerinin ön görülmesiydi. Çalışmanın yapıldığı dönemde 1600 erkek tutuklu ve hükümlünün bulunduğu E Tipi Kapalı Ceza İnfaz Kurumu’nda sağlık hizmetleri bir aile hekimi, bir diş hekimi, altı hemşire tarafından yürütülmekte, psikolog ve sosyal hizmet uzmanları tarafından psiko-sosyal hizmetler verilmektedir. Acil durumlar dışında tutuklu ve hükümlüler sağlık hizmeti almak istediklerinde dilekçe yazarak isteklerini kurum müdürlüğüne iletmekte, hekimin günlük iş listesine göre muayeneye çağrılmakta; gerektiği durumlarda hastaneye sevk edilmektedir. Hastaneye sevki gerçekleştirilen tutuklu ve hükümlülerin tanıları sevk edildikleri polikliniklerdeki hekimler tarafından; acil çağrılara ait ön tanılar ise ambulans ekibince konulmakta ve ceza infaz koruma memurları tarafından kayıtlara geçirilmektedir. Çalışmada kullanılan tanılar, hastane dönüşü kayıtlara geçen tanılardı. Tutuklu/hükümlülerin dosyalarında hangi kliniğe sevk edildiklerine dair bilgi olmadığı için klinik sınıflama, araştırmacılar tarafından sevk sonrası konulan tanılara göre gerçekleştirildi. Acil çağrılar ise ambulans ekibince konulan ön tanılara göre “tıbbi nedenler”, “kaza- travma ve yaralanmalar” ve “intihar” olarak sınıflandırıldı. Tutuklu/ hükümlülerin tutukluluk öncesi yaptıkları işlerin sınıflaması Uluslararası Standart Meslek Sınıflaması (ISCO-88)’na göre yapıldı. Acil çağrıların mevsimlere göre dağılımları değerlendirilirken, mevsimlerin tanımlaması “ilkbahar (01 Mart- 31 Mayıs)”, “yaz (01 Haziran- 31 Ağustos)”, “sonbahar (01 Eylül- 30 Kasım)”, “kış (01 Aralık- 29 Şubat)” olarak yapıldı. Yaş grupları “35 yaş altı” ile “35 yaş ve üzeri” olarak belirlendi. Aylık ve mevsimlik sevk sayıları, tüm sevkler üzerinden değerlendirildi. Başka bir ceza infaz kurumuna nakledilenlerin ve cezaevinden çıkan kişilerin dosyaları kapandığından bilgilerine ulaşılamadı. Dosyası açık olan tutuklu ve hükümlülere ait sevkler tüm sevklerin %33,3’nü oluşturmaktaydı.

Verilerin istatistiksel olarak değerlendirilmesinde veriye uygun tanımlayıcı istatistikler (sayı, yüzde, ortanca) hesaplandı. Analitik çalışma yapılmamış olmasına karşın, bazı değişkenler gruplandırılarak sevkler ile acil ambulans hizmet kullanımını etkileyen nedenler saptanmaya çalışıldı. Kategorik değişkenler bakımından yapılan istatistiksel karşılaştırmalarda ki-kare veya Fisher’s Exact test kullanıldı. İstatistik analizler SPSS v.11.5 paket programı ile yapıldı, istatistiksel önemlilik düzeyi 0,05 olarak dikkate alındı.

Bulgular

Tutuklu ve hükümlülerin tümünün erkek, yaş ortancasının 30,0 (min 18- max 68) yıl olduğu ve %4,8’inin okur-yazar olmadığı, %81,4’ünün ilköğretim ve altı eğitime sahip olduğu; %56,4’ünün bekâr, %7,4’ü boşanmış olduğu; %40,7’sinin sigara, %9,1’i alkol, %34,5’inin uyuşturucu/ uyarıcı madde kullandığı belirlendi. Kayıtlarda tutuklu ve hükümlülerin %65,3’ünün ilköğretim düzeyinde eğitim gerektiren, birinci ve ikinci ISCO beceri seviyesinde işler yaptığı belirlenirken (%34,8’i niteliksiz; %14,8’i hizmet ve satış elemanı, %11,1’i zanaatkâr; %4,6’sı sürücü) geriye kalanların işi %1,4’ü emekli; %1,1’i öğrenci ve%8,3’ü işsiz, %21,1’i diğer olarak belirtilmiş, on kişinin işi ise tanımlanmamıştı. Geçen bir yıllık dönemde toplam sevk sayısı 1491, sevk edilen tutuklu ve hükümlü sayısı ise 815’ti. Başvuruların en sık ocak ayında olduğu (tablo 1); dosyasına ulaşılan 351 tutuklu/ hükümlünün toplam sevkinin 495 olduğu, bu kişilerin %71,8’inin tek sevk aldığı ve sevk sayısının bir ile altı arasında değiştiği; sevklerde konulan tanıların %53,3’ünün sıklık sırasına göre göz, kas-iskelet sistemine ait sorunlar ile psikiyatrik sorunlardan oluştuğu görüldü (tablo 2). Son bir yıllık sürede 157 tutuklu ve hükümlü için 189 acil çağrı yapılmıştı (min 1- max 6); acil çağrı yapılan tutuklu ve hükümlülerin yaş ortancası 32 yıldı (min 16- max 68). Ambulans ekibinin ön tanılarına göre acil çağrı nedenlerinin başında tıbbi nedenler, ikinci sırada ise kaza- travma ve yaralanmalar gelmekteydi. Tıbbi nedenlerle yapılan çağrılarda 50 (%26,5) ağrı (baş, bel, böbrek, eklem, göğüs, karın, kas, mide gibi çeşitli organ ve dokulara ait); 22 (%11,6) ateş, ÜSYE, ASYE; 13 (%6,9) hipo-hipertansiyon, taşikardi-bradikardi; 11 (%5,8) anksiyete; 7 (%3,7) alerji- ürtiker; 7 (%3,7) epilepsi; 5 (%2,6) enfeksiyon; 4 (%2,1) astım ile 29 (%15,3) Ex, GİS kanama, glop, konversiyon, madde bağımlılığı, psikoz, romatizma, senkop gibi diğer tanılar konulmuştu. Acil ambulans kullanımı 35 yaş altında olan tutuklu ve hükümlülerde 35 ve üstü yaşta olanlara göre anlamlı düzeyde daha yüksekti (tablo 3).

Tartışma

Cezaevinde kalan tutuklu ve hükümlülerin sevk oranları genel nüfusa göre oldukça yüksektir [11] ve tutuklu ve hükümlülerin yarısı en az bir kez, sağlık problemi nedeniyle hastaneye sevk edilmiştir. Literatürde mahkûmların sağlık hizmeti kullanımının genel popülâsyondan yüksek olduğu belirtilmektedir; cezaevinde vakit geçirmektense hastanede vakit geçirmenin daha cazip gelmesi, cezaevi koşullarında hastalanma korkusunun yüksek olması gibi faktörlerin yanında cezaevindeki kurumsal kültür ve ilaçlara erişimlerinin sınırlı olmasından dolayı mahkûmların kendi kendine bakım olanaklarının kısıtlığının da bu durumda etkili olabileceği belirtilmektedir [8]. Yapılacak niteliksel çalışmalar, cezaevi popülâsyonunda sağlık hizmeti kullanımının neden daha yüksek olduğu anlamada yardımcı olabilir.

Türkiye’de 27 cezaevinde 2778 tutuklu ve hükümlü ile yapılan bir çalışmada, çalışma grubumuza benzer şekilde suçluların büyük bölümünün öğrenimini tamamlayamamış, orta yaşın altında kişiler olduğu belirtilmektedir [12]. Düşük eğitim seviyesi ile olumsuz çevre koşulları birleştiğinde sağlığı koruma ve geliştirmeye dönük faaliyetlerin azaldığı çalışmalarla gösterilmiştir [13,14]. Çalışmamızda da cezaevi popülâsyonu genç bir gruptan oluşmasına karşın, hem sevklerde hem de acil çağrılar içinde hastalıkların yaygınlığı bu durumu destekler görünmektedir. Tutuklu/ hükümlülerin acil ambulans kullanım oranı yüksek olup 98/1000/yıl olarak bulunmuştur. İzmir’ de bir çalışmada bu oran 14,8/1000/yıldır [15]. Bu durumda eğitim düzeyi, sosyoekonomik durum, madde kullanımı gibi tutuklu/ hükümlülere ait bireysel özellikler yanında cezaevi koşullarının ilave etkilerinin de olup olmadığı araştırılmalıdır.

Çalışmamızda sevklerin mevsimlere ve aylara göre dağılımı incelendiğinde en sık sevklerin kışın ve Aralık, Ocak ve Nisan aylarında olduğu saptanmıştır. Dosyası kapanan mahkûmların bilgilerine ulaşılamamasından dolayı hastalıkların mevsimlerle ilişkisi incelenememesine rağmen ortam ısısının düşmesinin vücut direncinin azalmasına yol açabilmesinin yanı sıra kapalı ve kalabalık ortamın hastalıkların yaygınlığı ve şiddetinin artmasında etkili olabileceği düşünülmüştür. Çalışmamızda İzmir’de genel popülasyondan farklı olarak acil ambulans hizmeti kullanımının mevsimlerle ilişkisinin olmadığı görülmüştür [15]. Bu durumda çalışma grupları arasındaki yaş, cinsiyet ile ambulans hizmeti kullanımı nedenlerinin farklılığı etkili olabilir.

Kayıtlarda sevk ve ambulans ekibi tarafından konulan tanıların bir kısmında belirti/ bulgular, bir kısmında ise hastalık adları yer almaktadır. Tanısı konan hastalıkların ICD-10’a göre kodlanması hastalıkların sınıflamasını ve takibini kolaylaştırabilir. Sağlık Bakanlığı İstatistiklerine göre toplumumuzda erkeklerde sıklıkla, kas iskelet sistemi problemleri (%9,3) ile hipertansiyon (%8,4) ve eklem hastalıkları (%5,4) görülürken, tutuklu ve hükümlülerde göz, kas iskelet sistemi ve psikiyatrik sorunlar ön plandadır [11]. Literatürde incinmeler, sırt ve boyun ağrısı, solunum yolu enfeksiyonu, alerji, dermatit gibi toplumda sıklıkla görülen minör hastalıkların cezaevindeki yaygınlığının genel popülâsyonla benzerlik gösterdiği ifade edilse de [8] çalışma grubumuzda sevk nedenleri arasında yer alması, birinci basamakta çözülmesi gereken bu sorunların ciddiyetinin artmış olabileceğine işaret edebilir.

Cezaevlerinde aşırı kalabalık birçok ülkeyi etkileyen yaygın bir sorundur ve mahkûmların sağlık ve iyilik hali üzerine olumsuz etkileri olduğu bildirilmektedir [16]. E tipi kapalı cezaevlerinin 600-1000 kişi kapasiteli olduğu belirtilmesine karşın [2] 1600 tutuklu ve hükümlünün bulunduğu bu cezaevinde, aşırı kalabalığın pek çok soruna yol açacağı öngörülebilir. Nitekim benzer durumdaki Konya E Tipi Ceza İnfaz Kurumu’na dönük TBMM İnsan Hakları İnceleme Komisyonu (2012)’nun hazırladığı raporda, aşırı kalabalık nedeniyle yetersiz fiziksel koşulların başta hijyen olmak üzere, ortak alan kullanımı, havalandırma ve sıcak su sağlama hususlarında sorunlara yol açtığı ifade edilmiştir [17]. Aşırı kalabalık, çalışma grubumuzda görülen cilt enfeksiyonu ve konjektivitte açıklayıcı nedenlerden olabilir. Literatürde yetersiz havalandırma, yüksek sıcaklığın bazı kirleticilerin konsantrasyonlarını arttırarak ve floresan aydınlatma ile irritan bir smog oluşturarak kronik konjuktivite ve nazal dolgunluğa neden olabileceği bildirilmektedir [18]. Tutuklu ve hükümlülerin yarıya yakınının sigara kullanması nedeniyle kalabalık ortamda sigara dumanına artmış maruziyet, bunun yanında ısınma amaçlı klima kullanımı literatürde belirtildiği şekilde göz kuruluğunda predispozan faktör olabilir [19].

Cezaevlerinde bulunanlar için bulaşıcı hastalıklardan tüberküloz önemli bir sağlık problemidir ve cezaevlerinde sıklığı toplumdaki oranların 10 ile 100 katı olabilmektedir [20]. Çalışmamızda tüberküloz şüphesi ile sevk edilen kişilerde ileri tetkiklerde tüberküloz bulunmaması sevindiricidir.

Çalışma grubumuzda, sevk alanları ve acil ambulans hizmeti kullanımı nedenleri arasında literatüre benzer şekilde psikiyatrik sorunlar ön plandadır. On iki ülkeden 23 bin mahkûmun katıldığı 62 araştırmanın sistematik derleme sonuçlarına göre, batı ülkelerinde, mahkûmlarda aynı yaş grubu popülâsyonla karşılaştırıldığında psikotik bozukluk ve majör depresyon riskinin dört kat, anti sosyal kişilik bozukluğunun 10 kat arttığı bildirilmektedir [5]. Ünver ve ark. (2013)’nca 685 mahkûmla yapılan bir çalışmada, mahkûmların %54,7’sinde orta ve ciddi düzeyde depresyon, %61,9’unda anksiyete ve %52,4’ünde stres belirlenmiştir [9]. Çalışmamızdaki psikiyatrik bozukluk yaygınlığı bu araştırmalardan düşük olsa da bunun nedeni sınırlı veriye dayalı olması; kurum hekimince müdahale edilenlerin ve tedaviye erişemeyenlerin bu rakamların dışında kalmasıyla ilgili olabilir.

Literatüre benzer şekilde çalışmamızda da mahkûmlar arasında madde bağımlılığı oldukça yüksektir [9,21]. Şiddet davranışının önde gelen kaynaklarından biri olarak madde bağımlılığının mahkûmlarda agresif davranışlarla daha fazla gerginliğe neden olduğu belirtilirken, suç öncesi madde kullanım öyküsü, suç anında madde etkisinde olma özelliğinin suç ve suça yönelimi artırdığı ve madde bağımlılığı olanlarda suç sayısının fazla olduğu ifade edilmektedir [9,10,12, 21]. Madde kullanımına ilişkin rehabilitasyon çalışmalarının cezaevi içinde yapılması, bağımlılıkla ilgili sağlık sorunlarının azalması yanında tekrar suç işlemeyi önlemede etkili olabilir.

Çalışmamızda sevklerde ve acil çağrı nedenleri arasında travma ve kesilerin yüksekliği dikkat çekicidir. Aynı cezaevinde yaptığımız diğer bir çalışmada mahkûmlar son altı ayda kendilerinin ya da diğer mahkûmların %13,4’ünün kırık çıkık/ burkulmalarla, %12,5’inin kesilerle karşı karşıya kaldıklarını ifade etmişlerdi [22]. Gerek sevklerde gerekse acil çağrılarda travma, kesi ve yaralanmalara ilişkin ayrıntılı kayıt tutulması bunların nedenlerini belirleme ve gerekli önlemleri almada yardımcı olabilir.

Çoğu ülkede mahkûmlarda kendine zarar verme ve intihar oranlarının toplumdan daha yüksek olduğu bildirilmektedir. On iki batı ülkesinde yapılan bir çalışmaya göre mahkûmlar arasında intihar oranları yüz binde 50-150 olarak bildirilirken [23] ülkemizde mahkûmlar arasında yaygınlığına ilişkin çalışmaya rastlanmamıştır. Genel nüfusta ise ülkeyi temsil eden bir çalışma olmamasına rağmen, bölgesel düzeyde yapılan bir çalışmada yaşam boyu intihar davranışının yaygınlık oranı %2,3 olarak bulunmuştur [24]. Çalışmamızda hem sevkler içinde hem de acil çağrılarda intihar girişimi sayısı genel popülâsyona benzerdir. Ancak bu sayılar kayıtlara geçen girişimler olup, cezaevi içinde yapılan müdahaleleri içermemektedir.

Literatürde suç işleyen kişilerin genellikle toplumda dezavantajlı kişiler olduğu ve sağlık hizmetleri kullanımlarının da daha sınırlı olduğu bildirilmektedir [8]. Görme kusurları, diş çürükleri gibi sorunların varlığı düşük eğitim ve sosyoekonomik düzeye sahip tutuklu ve hükümlülerin birikmiş sağlık sorunlarını cezaevine taşıdıklarını gösteriyor olabilir.

Yapılan çalışmalar pek çok kronik hastalığın mahkûmlar arasında daha yaygın olduğunu ve yaşla ilişkili hipertansiyon, diabet, astım, artrit oranlarının yüksek olduğunu göstermektedir [23,25]. Çalışma grubumuzdaki tutuklu ve hükümlüler ağırlıklı olarak kronik hastalıkların daha az görüldüğü genç yaş grubunda olmasına karşın madde kullanımı, cezaevi koşulları gibi nedenlerle daha erken yaşta kronik hastalıklara adaydır. Sevk edilenler arasında oldukça az sayıda kanserli mahkûm vardır. Gerek kronik hastalıklar gerekse kanserde erken tanı, tedavi ve bakım ihtiyaçları konusunda ihtiyaca dayalı bir planlama yapılabilmesi için ileri araştırmalara ihtiyaç vardır.

 Sonuç ve Öneriler

Çalışmamızın sonuçları literatüre benzer şekilde tutuklu ve hükümlülerin pek çoğunun -üst solunum yolu enfeksiyonundan kansere- ciddiyetleri değişen fiziksel ve ruhsal sağlık sorunlarına sahip olduğunu göstermektedir. Göz, kas iskelet sistemi sorunları ve psikiyatrik sorunlar sevk nedenlerinin başında gelirken, en çok tıbbi nedenlerle 112 acil yardım ambulans çağrısı yapılmıştır. Düşük eğitim ve sosyoekonomik düzey, yüksek riskli davranışlar yanında cezaevinin aşırı kalabalık olması, tutuklu ve hükümlüler arasında hastalık yaygınlığının artmasında etkili olabilir. Gelecek çalışmalarda cezaevinde sağlık hizmeti kullanımına etki eden tutuklu ve hükümlülere ait bireysel özellikler yanında cezaevi koşullarının da araştırılması önerilir.

 Araştırmanın sınırlılıkları

Kayıtlarının yetersizliği, dosyası kapanan bazı tutuklu ve hükümlülerin dosyalarına ulaşılamaması nedenleriyle değerlendirmeler sınırlı bilgiye dayalıdır. Örneklem seçimine gidilmeyerek dosyası açık olan tüm tutuklu ve hükümlülerin bilgileri kullanıldığı için aylara göre sevk nedenleri, hastalıkların mevsimlerle ilişkisi değerlendirilememiştir.

Teşekkür

Araştırmanın gerçekleştirilmesinde destek veren ceza infaz kurumu yönetimi ile çalışanlarına ve verilerin toplanmasında yardım eden Şenay Şermet’e teşekkür ederiz.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

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Emine Oncu, Sumbule Koksoy, Mehmet Ali Sungur. Referral to the Hospital And Emergency Ambulance Service Uses Patterns of the Inmates and Convicts. J Clin Anal Med. 2015;6(6):694-698

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Progesterone Supplement and Luteal Phase Deficiency in Unifollicular Intrauterine Insemination Cycles

Kadir Bakay, Fatih Aytekin, Nilufer Yigit Celik

Department of Obstetrics and Gynecology, Faculty of Medicine, Baskent University, Alanya, Antalya, Turkey

DOI: 10.4328/JCAM.2321 Received: 04.02.2014 Accepted: 13.03.2014 Published Online: 15.03.2014

Corresponding Author: Kadir Bakay, Baskent University Alanya Hospital, 07400, Alanya, Antalya, Turkey. GSM: +905308265868 E-Mail: drkadirbakay@gmail.com

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Aim: Intrauterine insemination is a widely used technique with advantages of being a simple and less invasive method with a lower cost when com-pared to other assisted reproductive techniques. In the present prospective randomized controlled study we aim to prove that progesterone supple-mentation is a beneficial factor in pregnancies achieved with intra uterine insemination and also we want to emphasise that luteal phase deficiency does not always occur in multifollicular cycles but can be seen in unifollicular cycles as well. Material and Method: Patients diagnosed with unexplained infertility between December 2011 and December 2012 were admitted to the study group. 278 IUI cycles with COH using recombinant FSH induction were recorded. Results: The effect of progesterone supplement on achieving pregnancy was statistically significant (p<0.05) with a rate of 33.66% when compared to the non-receiving group that had a rate of 12.22%. Discussion: Progesterone supplementation, either in defective luteal phase or not has a chance of improving pregnancy rates in general and contrary to the notion that luteal phase deficiency mainly occurs in multifollicular cycles, it can be seen in unifollicular patients as well.

Keywords: Intrauterine Insemination; Progesterone; Luteal Phase; Unifollicular

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Introduction

Intrauterine insemination (IUI) is a widely used technique with the benefits of being a simple and less invasive method with a lower cost in comparison to other assisted reproductive techniques (ART). Patient selection criteria, presence of various female infertility factors, differences in methods used for ovulation induction and management along with the number of cycles and variations in sperm parameters all affect success rates of the procedure.

Embryonic implantation occurs in the luteal phase, and a normal luteal phase is characterized by a normal hormonal environment, normal progesterone (P) secretion by the corpus luteum, and an adequate endometrial secretory transformation [1]. Luteal phase deficiency can be described as corpus luteum’s deficiency in preparing an adequate endometrial maturity. Therefore corpus luteum’s progesterone secretion is critical in achieving pregnancy and its healthy progression as long as trophoblastic cells are capable of adequate hormone synthesis and secretion [2]. Corpus luteum function is dependent on luteinizing hormone (LH) stimulation, and LH is dependent on gonadotropin releasing hormone (GnRH) secretion [2-3].

Different from natural cycles, controlled ovarian hyperstimulation (COH) often results in multifollicular development with higher steroid serum concentrations. LH serum level concentrations are usually low in GnRH agonist COH protocols due to prolonged suppression of hypothalamic GnRH secretion which also continues to compromise hypopituitaric LH secretion even after the stimulation phase, leading to the suggestion that higher serum steroid concentrations might have an adverse affect on LH secretion via said feedback mechanisms, which in turn results with premature luteolysis leading to corpus luteum deficiency and defective P secretion especially in multifollicular cycles [2]. In cycles with multifollicular growth, an advanced endometrium in the early luteal phase was observed in almost 50% of all patients [4].

In general it is widely accepted that luteal phase deficiency mostly occurs in multifollicular cycles by COH rather than natural cycles that tend to be unifollicular.

In the present prospective randomized controlled study we aim to prove that progesterone supplementation is a beneficial factor in pregnancies achieved with intra uterine insemination.

Material and Method

All authors listed state that the protocol for the research project has been approved by a suitably constituted Ethics Committee of the institution within which the work was undertaken.

All data were recorded in specific study forms and computer assigned randomization depending on odd/even number sequence for receiving or omitting progesteron supplement at admittance was performed.

All patients were required to fill and sign a specific informed consent form detailing the procedure

Patients diagnosed with unexplained infertility in our clinic from December 2011 to December 2012 were included in the study group. 278 IUI cycles with COH using recombinant follicule stimulating hormone (FSH) induction were recorded.

Patients that were unable to conceive while having regular ovulatory mensturations, normal hysterosalphingography (HSG) results with bilateral open tubal passage and a normal sperm analysis were considered as unexplained infertility.

Those with previous ovarian surgery, endocrine disorders (thyroid disfunctions, hyperprolactinema, polycystic ovarian syndrome), obese patients (body mass index above 30) were excluded from the study group and 87 cycles, that were multifollicular, were excluded from the study group as well but continued on receiving progesterone, (multifollicular cycles were specifically excluded from the study group in order to show if luteal phase deficiency occurs also in unifollicular cycles).

Ninety IUI cycles did not receive progesterone supplement of which 11 pregnancies were achieved while on the other hand 101 cycles received progesterone supplement of which 34 pregnancies were achieved.

All patients were evaluated by ultrasonography (USG) and basal hormone levels on the 2nd day of the cycle before administering 75 IU of recombinant FSH daily and reevaluated on the 7th day with USG. Multifollicular cycles were excluded from the study group and after confirming a single follicule of at least 21-22 mm in diameter, choriongonadotropine 250 µg was administered to assure ovulation followed by intra uterine insemination exactly 36 hours later. Twenty four hours after IUI, 100 mg progesterone supplement of thrice a day orally was initiated.

Since there is no single definitive method for defining luteal phase deficiency, laboratory tests measuring P levels at mid-luteal phase (day 21) before the IUI cycle were obtained nonetheless to support diagnosis.

Patients who had serum progesterone levels of < 6.0 ng/ml on day 21 before the IUI cycle were designated to have luteal phase deficiency.

As an ethical precaution, patients with low P levels that were designated by the computer to “not receive” progesterone were omitted from the study group but continued on standard IUI protocol receiving P supplement. So in a way, comparison was made between both unifollicular groups; one with luteal phase deficiency (101 patients) and one with no deficiency (90 patients) according to day 21 progesterone levels.

Pregnancy was confirmed 12 days after IUI by serum βhCG levels, and progesterone supplement was continued until 12th week.

Multifollicular cycles continued on their IUI protocol but their data was not included in the study.

The primary outcome measures were pregnancy and live birth. Efficacy of progesterone supplementation according to comparison of pregnancy and live birth rates between treatment and control groups were performed by Mann-Whitney U test. A P value of < 0.05 was considered to be statistically significant and considered as proof of progesterone treatment as a beneficial option in achieving and continuing a healthy pregnancy (Table 1).

Results

Eleven pregnancies were achieved in 90 patients that did not receive progesterone supplement resulting in a pregnancy rate of 12.22% while on the other hand 101 patients received progesterone supplement of which 34 pregnancies were achieved resulting in a pregnancy rate of 33.66%. Live birth rate was 97.05% for the progesterone receiving group with one case of an anencephalic fetus terminated at 12th week of gestation. Live birth rate was 100% for the other group. The effect of progesterone supplement on achieving pregnancy was statistically significant (P = .05) with a rate of 33.66% when compared to the non-receiving group that had a rate of 12.22% [Table 1].

Conclusion

Naturally one or two dominant follicules are usually enough for the phyisiological feedback mechanism to function properly in a healthy woman but various ovulation induction protocols tend to produce multifollicules resulting in higher concentrations of serum estradiol (E) and progesterone levels thus inhibiting FSH and LH secretion causing very low levels of LH synthesis and secretion. Inhibin A is also known to have an effect in this, along with high E and P levels.

Lower LH presence is the reason for corpus luteum deficiency leading to progesterone deficiency and a shorter luteal phase, all of which is in general described as the luteal phase deficiency.

Patients with luteal phase deficiency are known to have fewer progesterone receptors on the nuclei of endometrial glandular cells therefore this previously mentioned inadequate endometrial structure is either because of these fewer receptors or low levels of progesterone [5-6].

In light of these evidences describing the physiological mechanisms leading to lower progesterone levels, the simple solution of providing the decreased progesterone led us to research the subject and deem if it is truly a beneficial treatment option.

Though Erdem, Hamilton and various other authors are supporting progesterone supplementation, authors like Keenan, Moghissi and Ebrahimi are against it [7-8]; [9-10].

According to our study results we are in favor of progesterone supplementation.

In the material and methods section we mentioned that specifically unifollicular cycles were chosen for the study group and since progesterone usage is the only known treatment for luteal phase deficiency, the outcome of the study shows that pregnancy rates were statistically better in the progesterone receiving group hence leading us to reason that luteal phase deficiency is indirectly proven to be an occurence in both groups, meaning also that day 21 progesterone levels is not a definitive method in diagnosis and finally since both groups are unifollicular this points out that luteal phase defeciency is not dependent on the number of follicules in a cycle.

There is also a debate on the way progesterone is administered. While Erdem et al. suggests daily vaginal usage of 90 mg progesterone gel, Ebrahimi et al. used daily vaginal usage of 400 mg of progesterone pessaries [8,10]. In our study group we preferred 100 mg of progesterone tablets orally thrice a day. The way progesterone is used is another study subject on the assumption of its benefit on improving pregnancy rates.

In conclusion, even though there are many different results obtained from various ovulation induction protocols, larger study groups involving multiple centers are still needed in this research subject to solidify a worldwide treatment protocol to be used in assisted reproductive techniques.

Competing interests

The authors declare that they have no competing interests.

References

1. Tavaniotou A, Albano C, Smitz J, Devroey P. Impact of ovarian stimulation on corpus luteum function and embryonic implantation. J Reprod Immunol 2002;55: 123–30.

2. Fauser BC, Devroey P. Reproductive biology and IVF: ovarian stimulation and luteal phase consequences. Trends Endocrinol Metab 2003;14: 236–42.

3. Filicori M, Butler JP, Crowley WF Jr. Neuroendocrine regulation of the corpus luteum in the human. Evidence for pulsatile progesterone secretion. J Clin Invest 1984;73: 1638–47.

4. Garcia JE, Garcia JE, Acosta AA, Hsiu JG, Jones HW Jr. Advanced endometrial maturation after ovulation induction with human menopausal gonadotropin/human chorionic gonadotropin for in vitro fertilization. Fertil Steril 1984;41: 31–5.

5. Jokobs M, Balesch J, Merio J. Endometrial cystosolic and nuclear progesterone receptors in the luteal phase deficiency. J Clin Endocrinol Metab 1987;64: 672.

6. Uysal A, Taner CE, Mun S, Coşar E. The role of endocrine and endometrial factors in cases of recurrent miscarriage: A tertiary center experience. J Clin Anal Med 2013; DOI: 10.4328/JCAM.1996

7. Hamilton CJ, Jaroudi KA, Sieck UV. The value of luteal support with progesterone

in gonadotropin-induced cycles. Fertil Steril 1993;60: 786–90.

8. Erdem A, Erdem M, Atmaca S, Guler I. Impact of luteal phase support on pregnancy rates in intrauterine insemination cycles: a prospective randomized study. Fertil Steril 2009;91: 2508–13.

9. Keenan JA, Moghissi KS. Luteal phase support with hCG does not improve fecundity rate in human menopausal gonadotropin-stimulated cycles. Obstet Gynecol 1992;79: 983–7.

10. Ebrahimi M, Asbagh FA, Darvish S. The effect of luteal phase support on pregnancy rates of the stimulated intrauterine insemination cycles in couples with unexplained infertility. Int J Fertil Steril 2010;4: 51–6.

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Kadir Bakay, Fatih Aytekin, Nilufer Yigit Celik. Progesterone Supplement and Luteal Phase Deficiency in Unifollicular Intrauterine Insemination Cycles. J Clin Anal Med. 2015;6(6):691-693

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Comparing Trans Obturator Tension Free Vaginal Tape Surgery with Needleless Suburethral Sling

Kadir Bakay, Fatih Aytekin, Nilufer Yigit Celik

Baskent Universitesi Kadın Hastalıkları ve Doğum Kliniği, Alanya Hastanesi, Antalya, Alanya, Turkiye

DOI: 10.4328/JCAM.2320 Received: 04.02.2014 Accepted: 08.03.2014 Published Online: 10.03.2014

Corresponding Author: Kadir Bakay, Baskent University Alanya Hastanesi Alanya, Antalya, Türkiye. GSM: +905308265868 E-Mail: drkadirbakay@gmail.com

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Aim: Urinary incontinence is described by the International Continence Soci-ety as an involuntary urinal discharge that can be objectively proved to cause hygenic and social problems. We aim to share our surgical experience in 51 patients in which trans obturator tension free vaginal tape procedure [TOT] is compared with needleless suburethral sling placement, also known as min-isling. Material and Method: 51 patients complaining of genuine stress incon-tinence between December 2011 and December 2012 were retrospectively involved in the study group. All patients were examined and urodynamically tested for diagnosis. After getting positive results as genuine stress incon-tinence, surgery was planned. Patients were operated using outside-inside TOT technique and minisling technique, results were compared in terms of blood loss, operation time, and the surgical effectiveness of the technique. Results: Operation time was 27 ± 6 minutes for TOT and 11 ± 4 minutes for minisling respectively. Comparison of operation time and blood loss was in favor of the minisling group. Disscussion: TOT and minisling are both de-scribed as minimally invasive procedures that can be performed under re-gional anesthesia to an outpatient with minisling bearing all the advantages of TOT without needle complications.

Keywords: Tot; Minisling; Incontinence; Tension Free; Vaginal Tape

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Introduction

International Continence Society describes urinary incontinence as an involuntary urinal discharge objectively proved to cause hygienic and social problems [1-2].

The main reasons for incontinence, in about 95% of patients, are urethral sphincter deficiency or unwanted detrussor contractions [3]. Therefore it is very important to distinguish between incontinence types in diagnosis, of which, treatment is remarkably different, for each subtype [3].

Detailed patient history and a proper pelvic examination to especially identify anatomical defects and certain urogynecological tests like the uroflow urodynamic measurements, valsalva and Q-tip test is performed to help in diagnosis [4]. Urinary incontinence should always be taken for serious whenever it is encountered in a woman’s life and carefully studied using necessary urogynecological diagnostic measures to identify the underlying pathology and to act accordingly to provide an effective and appropriate treatment modality [5].

Conservative options like medical treatment, pelvic and periurethral muscle physiotherapy, mechanical devices and behavioral therapy can be described along with surgical procedures that are used in urethral sphincter deficiency but there is still no consensus on which treatment modality should be used primarily on these patients [6].

Therefore it is very important do decide on which kind of surgical operation should be performed along with a careful study of the underlying pathophysiology using specific urogynecological diagnostic procedures.

Here in this study we aim to share our surgical experience in incontinence patients that were complaining of genuine stress urinary incontinence [SUI], in which outside-inside trans obturator tension free vaginal tape procedure [TOT] is compared with needleless urethral sling placement, (Contasure-Needleless Sling) also known as minisling, in terms of blood loss, operational time and complications.

Material and Method

Our study is based retrospectively on a total of 51 patients complaining of genuine stress incontinence between December 2011 and December 2012. Urinary culture tests were performed to rule out any infectious cause, 10 patients were in the post-menopausal period and were excluded from the study group to rule out incontinence due to vaginal atrophy since we aim to compare surgical results. In those patients medical treatment with vaginal estradiol was preferred.

The remaining 41 patients were carefully examined for stress incontinence, asked to perform a valsalva, asked to fill out a specifically prepared form and tested [Q-tip test] for diagnosis. Patients in the study group were required to complete a specifically designed questionnaire detailing their complaints which also included Stress, Emptying, Anatomic, Protection and Instability [SEAPI] scores pre and post operatively [in the first, third and sixth months after the operation]. The questions concerned risk factors and consequences of female urinary incontinence, its diagnosis and clinical assessment, urodynamic investigations, conservative treatment, surgical treatment, complications of suburethral tape surgery and the association of pelvic organ prolapse and urinary incontinence. Afterwards surgery was planned, 21 patients were operated using the outside-inside TOT technique using material made of polypropylene monofilament mesh approximately 450×11 mm with a plastic cover with ends that are attached to stainless steel introducer needle used for placement. 20 patients were operated with minisling without using the guide needle to pass through the obturator fossa. In these 20 patients only a sub-urethral vertical incision was made followed by mucosal dissection to enable the fixation and placemet of the synthetic sling which is made of polypropylene monofilament, with dimensions of approximately 114×12 mm which has ends that are slightly wider as they form a pocket to provide sling tissue ingrowth helping the sling maintain stability under urethra (Figure 1).

All patients were recalled for urogynecological examination to reevaluate the surgical outcome in the first, third and sixth months after the operation respectively.

Surgical cure was defined as no involuntary urinal discharge with valsalva in the first, third and sixth months along with no subjective complaints of incontinence in post operative reevaluation.

All authors declare that all experiments have been examined and approved by the appropriate ethics committee in which the study was undertaken.

Results

Statistical Study Methods

Mann-Whitney U test was used for comparing data and the results were evaluated in a 95% safety zone and a P value lower than 0.05.

Patients were all multiparous with a mean age of 41 ± 3,2 and a mean parity of 2±1. Patients were all discharged in postoperative day 1, no significant blood loss was noted in both groups, with a mean of 110 ± 15cc in the TOT group and 65 ± 10cc in the minisling group respectively. Blood loss, when compared between two groups was statistically lower in the minisling group (p=.05).

Mean operation time was 27 ± 6 minutes for TOT and 11 ± 4 minutes for minisling respectively. Operation time, when compared between two groups was noticably shorter in the minisling group (p=.05).

Nineteen out of 21 patients (cure rate: 90.47 %) in the TOT group and 18 out of 20 patients (cure rate: 90%) in the minisling group were found to be cured of stress incontinence when reevaluated in the first, third and sixth months after the operation.

Mesh extrusion was observed in 2 patients in both groups in post operative first month, designated as surgical failure, said patients were re-operated using same techniques.

Urogynecological examinations were performed to confirm these foundings both objectively and subjectively (Table1, Table 2).

Discussion

Although there is stil no consensus, when surgery is the planned course of action, the “integral theory” introduced by Petros and Ulmsten that emphasizes the importance of fixation at the mid-urethra instead of at the level of the bladder neck is generally the widely accepted notion at present [7]. Loosely applied mid-urethral sling placement is considered to be the new gold standard therapy for female stress incontinence. TOT is described as a minimally invasive procedure that can be performed under local anesthesia to an outpatient. In this procedure sub-urethral anatomic reinforcement and suspension is provided without needing to reposition the bladder or the need to hook up the periurethral tissue to the pelvic structures as if in a Burch operation [8]. Klutke JJ mentioned that, in a similar procedure that backs up and suspends sub-urethral anatomy, urethral resistance tends to rise in patients while urinating, resulting in continence [9].

In general sling operations, as a procedure, have the advantage of being able to be performed over patients that had been previously operated due to incontinence using different techinques and it is an operation that can be combined with other gynecological operations such as hysterectomy [10-11-12-13].

Since it is usually performed under local or regional anesthesia it gives the surgeon the chance to evaluate the success of the operation per operatively to determine if continence had been achieved hence improving cure rates dramatically. Our cure rates were slightly higher than what is generally reported in the current literature, we assume that was due to the size of our study group.

Complications, though rare in the outside-inside technique, such as obturator artery damage, visceral damage, mesh extrusion caused by vaginal fistulae may occur mainly during the insertion of the guide needle.

Minisling procedure on the other hand, has all the advantages of TOT without needle complications and also is a much shorter and controlled surgical procedure mainly because the guide needle is not required to pass through obturator fossa into the sub urethral space to place the sling. But then again it would be unwise to assume it does not have its own complications, such as mesh extrusion, as was observed in our study group, which is a significant cause of surgical failure in minisling technique, mostly because of incorrect placement and usually requires re-operation.

We are aware that comparing different surgical techniques is always a difficult subject due to numerous variables that may or may not have been taken into effect but when everything discussed above is considered, it can be safe to conclude that minisling is an effective and easy to learn surgical technique that has significant lower rates of complication and many other advantages including shorter hospital stay, short term catheterization, shorter operational times and fewer blood loss with similar cure rates when compared to TOT and other techniques concerning treatment of genuine stress incontinence and yet for more definitive conclusions new studies including larger groups are always in demand.

Competing interests

The authors declare that they have no competing interests.

References

1. Abrams P, Blavias JG, Stanton SL, Anderson JT. The Standardization of terminology for lower urinary tract function. Br J Obstet Gynaecol 1990;97:1-16

2. Kelleher C. Epidemiology and classification of urinary incontinence. In: Urogynecology Cordozo L. Curchill Livingstone, NewYork. 1997. p.3-26

3. Weber AM, Taylor RJ, Wei JT, Lemack G, Piet Monte MR, Walters MD. The cost effectiveness of preoperative testing for stress urinary incontinence in women. BJU Int 2002;89:356-63.

4. Walsh LP, Zimmern PE, Pope N, Shariat SF. Comparison of the Q-tip test and voiding cystourethrogram to assess urethral hypermobility among women enrolled in a randomized clinical trial of surgery for stress urinary incontinence. J Urol 2006;176:646-50.

5. Yalçın ÖT. Ürojinekoloji. In: Temel Kadın Hastalıkları ve Doğum Bilgisi. Kişnişçi H, Gökşin E, Üstay K. Güneş Kitapevi.Ankara. 1996.p.730-47

6. Bergman A, Elia G. Three surgical procedures for genuine stress incontinence. Five year follow up of a prospective randomized study. Am J Obstet Gynecol 1995;173:66-72.

7. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence: Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl 1990;153:7-31.

8. Burch JC. Cooper’s ligament urethrovesical suspension for urinary stress incontinence. Am J Obstet Gynecol 1968;100:764-72.

9. Klutke JJ, Klutke CG, Carlin B. Altered voiding after the tension free vaginal tape procedure, is increased resistance the mechanism of therapy? Obstet Gynecol 2000;95: 55.

10. Liapis A, Bakas P, Creatsas G. Burch colposuspension and tension free vaginal tape in the management of stress urinary incontinence in women. Eur Urol 2002;41:469-73.

11. Ward K, Hilton P, Browning J. A randomized trial of colposuspension and tension free vaginal tape for primary genuine stress incontinence. Neurourol Urodynam 2000;19:385-6.

12. Peschers U, Tunn R, Buczkowski M, Perumlhini D. Tension free vaginal tape for the treatment of stress urinary incontinence. Clin Obstet Gynecol 2000;43:670-5.

13. Mit T, Uysal A, Camcuzcuoglu H, Tınar S, Koyuncu T, Sonmez S. Comparison of TOT and TVT in treatment of female stres urinary incontinence. J Clin Anal Med 2013 DOI: 10.4328/JCAM.1707.

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Kadir Bakay, Fatih Aytekin, Nilufer Yigit Celik. Comparing Trans Obturator Tension Free Vaginal Tape Surgery with Needleless Suburethral Sling. J Clin Anal Med. 2015;6(6):688-690

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The Risk Factor and The Severity of Symptoms Relation in Women with Overactive Bladder

Mehmet Tulga Eğilmez

Baskent University School of Medicine, Adana Clinic and Research Center, Department of Urology, Adana, Turkey

DOI: 10.4328/JCAM.2359 Received: 21.02.2014 Accepted: 05.03.2014 Published Online: 09.03.2014

Corresponding Author: Mehmet Tulga Eğilmez, Başkent Üniversitesi Tıp Fakültesi, Adana Uygulama ve Araştırma Hastanesi, Yüregir, Adana, Türkiye. T.: +90 3223272727 F.: +90 3223271274 E-Mail: tulgaegilmez@yahoo.com

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Aim: To investigate whether risk factors for overactive bladder (OAB) in women are associated with symptom severity and to assess the impact of symptom severity on the quality of life. Material and Method: Symptoms of 100 female patients (aged, 47.70 ± 12.34 years) who were diagnosed with OAB were assessed using the Boyarsky symptom score (BSS). Data for age, educational status, body mass index (BMI), chronic disease, vaginal deliver-ies, constipation, smoking, consumption of alcohol, tea, coffee, or carbonated drinks and diets involving spicy food were recorded. Subcategories for each factor regarding quantity were established. The findings were statistically correlated with the BSS and with each urinary symptom individually. Each pa-tient’s quality-of-life (QoL) scores were correlated with the severity of each symptom and the total, obstructive and irritative BSS. Results: Urgency was related with BMI, spicy food, vaginal deliveries, menopause, and advanced age. Nocturia had a relation with menopause and advanced age. Total BSS was significantly correlated with coffee consumption. Irritative BSS was cor-related with menopause and advanced age and obstructive BSS was cor-related with constipation. Total and irritative BSS were both positively cor-related with the QoL score. Discusion: Risk factors can affect the severity of symptoms and these factors should be considered when planning therapy.

Keywords: Bladder Dysfunction; Overactive Bladder; Urinary Symptoms

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Introduction

Overactive bladder (OAB) is a syndrome defined as urinary urgency with or without urge incontinence, usually with increased daytime frequency and nocturia [1]. Epidemiologic studies have revealed wide variance in prevalence rates of OAB. Rates between 11 to 53.1% have been reported [2,3]. These investigations have also revealed many risk factors for OAB including age, body mass index (BMI), nutritional habits, living conditions, number of vaginal deliveries, smoking, alcohol and caffeine consumption. Some of these factors can result in permanent changes of the detrusor muscle itself and/or of the nerve supplying the detrusor. It is unclear whether risk factors for OAB are related strictly to the development of the disease or whether they also influence the severity of lower urinary tract symptoms (LUTS).

Urgency is the sine qua non criterion that is solely enough for the diagnosis of OAB, while increased daytime frequency and nocturia may or may not be present. Patients diagnosed as OAB may have other LUTS that are not present in the diagnostic criteria for OAB. Studies investigating the risk factors for LUTS revealed separate risk factors for nocturia and urgency [4]. This raises the question: does each symptom of the OAB have different risk factors? The aim of this study was to evaluate the risk factors of each symptom (i.e. urgency, nocturia, increased daytime frequency) separately, to investigate whether the quantity of each factor has a relation with symptom severity and to assess the impact of symptom severity on the quality-of-life (QoL).

Material and Method

The study was prospectively designed and involved 127 consecutive female OAB patients (age range, 18-76 years; mean, 47.70 ± 12.34 years) who presented to the urology outpatient clinic. The study was approved by the university Ethics Committee and informed, written consent was obtained from all subjects.

In each case, fasting glucose and serum creatinine levels were measured and urinalysis, urine culture and uroflowmetry were performed. Depending on the findings, further investigations with urinary system imaging, cystoscopy or conventional urodynamic studies were performed when necessary. Patients who had urinary tract infection, urolithiasis, microscopic hematuria, uroflowmetry findings concordant with obstruction (maximum flow of <15 mL/s and an uroflowmetry curve other than a normal bell–shaped voiding pattern), postvoid residual more than 50 ml, those taking diuretics, alpha-blockers or drugs that may have an effect on bladder sensation and normal detrusor function were also excluded from the study. Severity of symptoms of the remaining 100 patients, who were eligible for the study, was evaluated by the Boyarsky symptom score. To document this, patients completed the self-administered symptom scoring system evaluating the severity of voiding (obstructive) and storage (irritative) symptoms. The system allows 0 to 3 points for each of the 9 questions for a total Boyarsky score with a maximum of 27 points. The obstructive symptom score was calculated, being the sum of responses to questions relating only to slow stream, hesitancy, terminal dribble, intermittency and feeling of incomplete emptying (total possible score 15). The irritative symptom score was calculated for the remaining irritative symptoms (urgency, nocturia, increased daytime frequency and dysuria) with a total possible score of 12.

Age, educational status, Body Mass Index (BMI), history of chronic disease, number of vaginal deliveries, constipation, smoking frequency, consumption of alcohol and dietary factors such as tea, coffee, carbonated drinks and spicy food were recorded for each case and subcategories for each factor regarding quantity were established. The number of patients in each subcategory was recorded (Table 1). Correlation analysis was performed for the assessment of the relation between the findings for each risk factor and the patients’ Boyarsky symptom scores. The relation between the quantitative amount of each factor and each different OAB symptom was statistically analyzed. Each patient’s quality of life was assessed using the QoL questionnaire of the International Prostate Symptom Score and these scores then were correlated with the severity of each symptom and the total, obstructive and irritative BSS. Spearman’s rank correlation coefficient (rho) test was used for statistical analyses. All calculations were done using SPSS (Statistical Package for the Social Sciences) version 14software. A ‘p’ value ≤ 0.05 was considered significant. Definitions in this study confirm to the standards recommended by the International Continence Society [1].

Results

Urgency had a statistically significant correlation with BMI, spicy food, vaginal delivery number, menopause and advanced age (Table 2). Nocturia had a correlation with menopause and advanced age. Increased daytime frequency had no statistically significant correlation with the risk factors included in the study but patients with urgency usually also had increased daytime frequency. Patients with increased daytime frequency usually also had an accompanying urgency or nocturia symptom and these findings were statistically significant. A positive directional relation between the severity of urgency and the quantity of the risk factors was found. The relation was very weak for BMI, spicy food and number of vaginal deliveries and weak for age and menopause. The relation with nocturia was positively very weak for menopause and weak for age.

Urgency, increased daytime frequency and nocturia had a strong positive relation with the irritative BSS (p<0.001 and r=0.673). In addition to urgency, increased daytime frequency, and nocturia, which are the criteria for the diagnosis of OAB, 81 (81%) of the patients also had one or several other LUTS (Table 3). These symptoms were assessed by the Boyarsky symptom score. Total, irritative, and obstructive Boyarsky symptom scores were found to be 10.1±4.7, 6.2±2.0, and 3.8±2.7, respectively. Total Boyarsky symptom score had a statistically significant correlation and a strong positive relation with coffee drinking and constipation (Table 4). Women who drank at least 1 cup of coffee per day had a higher total BSS than those who drank rarely or no coffee. Higher irritative BSSs had a positive and weak relation with menopause and advanced age. A strong positive relation was found between higher obstructive Boyarsky symptom scores and constipation.

The patients’ mean QoL score was 4.61 ± 1.18 (Table 3). Irritative and total Boyarsky symptom scores had a positive relation with the QoL score (Table 4). But each individual OAB symptom did not show a statistical significant correlation with the QoL score when analyzed separately (Table 2).

Educational status; history of chronic disease; smoking; and consumption of alcohol, tea, and/or carbonated drinks were not statistically correlated with the severity of symptoms or the BSSs.

Discussion

Overactive bladder is a syndrome that has serious negative impact on quality of life. The International Continence Society defined this condition as “urgency with or without urge incontinence, usually with frequency and nocturia” [1]. However, some patients with OAB also have other LUTS in addition to this combination. Jeffery et al. [5], using uroflowmetry and assessment of urinary residual volume, have examined the relationship between symptoms of voiding dysfunction in women and the objective measurements of voiding dysfunction. In their study group, 50% of the patients had at least one symptom of voiding dysfunction. Only 6.9% of the patients had an abnormal flow curve and 82.1% of the women had a normal bell-shaped voiding pattern. Their results supported the study of Haylen [6] which the relationship between voiding symptoms and objective parameters were also investigated. These studies show that only a small proportion of women with voiding symptoms have voiding dysfunction on objective tests. In this study, although patients with uroflowmetry findings and post void residual concordant with obstruction were not included in the study, 81% of the remaining 100 patients also had voiding complaints of varying severity. Therefore, in addition to the relation between the risk factors and the OAB symptoms, the relation between these risk factors and the obstructive symptoms listed in the Boyarsky scoring system has also been investigated. Boyarsky symptom score has been previously validated and has been used to assess LUTS in previous studies [7].

Increased BMI, increased spicy food consumption, and higher number of vaginal deliveries appear to be the risk factors for the severity of urgency, while menopause and advanced age are the risk factors for nocturia. However, evaluation of the symptoms which are not among the diagnostic criteria of OAB showed that coffee and constipation also appear to be risk factors which effect the severity of LUTS in patients with OAB. These results indicate the need for an overall evaluation of the OAB patient not only focusing on the current diagnostic criteria but on all existing LUTS symptoms and the related risk factors.

Age and menopause: Previous research has demonstrated a correlation between advanced age and detrusor overactivity [8]. As a woman ages, factors such as reduced bladder capacity, estrogen deficiency, neural control, and connective tissue changes in the bladder are all thought to contribute to development of OAB [9]. Findings related to the effects of menopause on stress or urge urinary incontinence are conflicting [10,11]. In this study, in concordance with these previous studies, it was found that age and menopause was positively correlated with both urgency and nocturia. However, it is difficult to determine whether this relation is specifically related to menopause or to advanced age in general.

Obesity: BMI is a risk factor for urinary incontinence. Obesity can increase intraabdominal and intravesicular pressure. In turn, this chronic stress can lead to pudendal nerve damage, resulting in pelvic floor dysfunction [12]. BMI >30 kg/m2 is accepted as a risk factor in both sexes [13]. Furthermore, it has been shown that obese female patients experience a relief in urge incontinence after losing weight [14]. In this series, there was a positive correlation between BMI and severity of urgency.

Constipation: Constipation is defined as <3 defecations in a week. Coyne et al. have shown that in both sexes, constipation is encountered more in OAB patients compared to the patients without an OAB [15]. Similar to the mechanism triggered by obesity, it has been suggested that chronic constipation also has negative effects on the nerve supply to the pelvic floor muscles that can cause OAB symptoms [11].The data of this study has shown that an association exists between chronic constipation, total and obstructive symptom severity. Constipation should be considered a contributing factor to OAB and patients should be instructed to consume fibrous foods as a component of therapy.

Vaginal delivery: Vaginal delivery has been shown to damage the peripheral nerves of the pelvis, and consequently leads to bladder hypersensitivity and hyperactivity [16]. Work by Lapitan and Chye [2] revealed that more than two vaginal deliveries are strongly associated with development of OAB. In agreement with their results, this study has shown that number of vaginal deliveries is positively correlated with the severity of urgency.

Coffee, tea, carbonated drinks and spicy food: Caffeine is known to have a diuretic effect and to stimulate the smooth muscle fibers of the detrusor by increasing detrusor pressure and detrusor muscle exitability [17]. Research by Bryant et al. [18] has shown that reduction of caffeine on diets in patients with urinary symptoms is associated with reduced urgency and frequency. The effect of caffeine seems to be dose dependent and daily caffeine consumption should be limited to <200 mg/day keeping in mind that tea chocolate and some carbonated drinks also contain caffeine [19]. The effect of tea, coffee and carbonated drinks on OAB is controversial. Dallosso et al. [20] reported that there is no effect of coffee or tea on OAB. On the other hand, Yeniel et al. [21] have found a significant relationship between 5 or more units of tea and OAB. In this study, coffee consumption was positively correlated with severity of symptoms but a relation between each individual symptom was not found. The majority of the patients in this study group (74%) were drinking less than 5 cups/day which may have had an effect on the results. On the other hand, spicy food had a statistically significant correlation and a positive very weak relation with urgency.

Smoking and alcohol: Dalloso et al. [20] have identified smoking as a risk factor for OAB. Likewise, alcohol consumption can have irritating effects on the bladder and also cause diuresis [22]. Nicotine has been shown to increase phasic detrusor contractions in pigs and to induce detrusor overactivity in cats [23,24]. Furthermore, intra-abdominal pressure increase caused by coughing due to smoking is thought to be one of the adverse effects leading to bladder dysfunction. This study revealed no correlation between smoking or alcohol use and OAB symptom severity. But it should be noted that 71% of the patients enrolled in the study were nonsmokers and 94% did not drink alcohol.

Chronic disease: It is also a well-established fact that chronic diseases, such as diabetes mellitus and hypertension, are associated with OAB [25]. These conditions can play etiological roles in OAB via different mechanisms; however, this study failed to reveal any association between presence of chronic disease (diabetes mellitus or hypertension) and OAB symptoms. In this study, patients using drugs that may have an effect on bladder sensation and normal detrusor function such as diuretics, alpha-blockers, calcium antagonists were excluded from the study which may have had an effect on the results by leaving patients with less severe chronic disease to be included in the study.

The majority of the women in the study (81%) stated that OAB had a negative impact on their quality of life and have marked the mostly dissatisfied, unhappy or terrible options on the QoL questionnaire (Table 3). The QoL score and each individual symptom did not show a statistically significant correlation. But the QoL scores had statistically significant relations with the total and irritative Boyarsky scores. These results may reflect that the symptom complex as a whole is the reason for deterioration of the QoL and not each individual symptom by itself.

OAB is a syndrome that has important negative impact on quality of life and is not necessarily the same disease process in every patient. It is rather a collection of symptoms that create bother caused by one of many possible disease processes. These patients would benefit from a chronic care model in which the focus shifts from curing the disease, which in fact is unrealistic, to optimizing symptom management. Coffee drinking, constipation, obesity, spicy food consumption, higher number of vaginal deliveries, menopause, and advanced age all can influence the severity of OAB symptoms. This study shows that risk factors may vary according to the symptoms.

Conclusion: Concomitant symptoms are also major causes of decreased quality of life as much as urgency in female patients with OAB. Apart from the consistent risk factors, such as age and number of vaginal deliveries that cannot be manipulated, regulation of the changeable risk factors such as quitting smoking, weight loss in overweight patients, treatment of constipation, decreasing the daily caffeine consumption, may have positive impact on the success of treatment.

Competing interests

The authors declare that they have no competing interests.

References

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Mehmet Tulga Egilmez. The Risk Factor and The Severity of Symptoms Relation in Women with Overactive Bladder. J Clin Anal Med. 2015;6(6):683-687

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Heart Surgery Experience in Hitit University Faculty of Medicine Çorum Research and Training Hospital: First Year Results

Adem İlkay Diken 1, Adnan Yalçınkaya 1, Seyhan Yılmaz 1, Eray Aksoy 1, Emrah Ereren 1, Yasemin Höbek Aydın 2, Mustafa Paç 3, Kerim Çağlı 1, 3

1 Hitit Üniversitesi Tıp Fakültesi, Kalp ve Damar Cerrahisi, Çorum, 2 Hitit Üniversitesi Tıp Fakültesi, Anestezi ve Reanimasyon Kliniği, Çorum, 3 Türkiye Yüksek İhtisas Hastanesi, Kalp ve Damar Cerrahisi, Ankara, Türkiye

DOI: 10.4328/JCAM.2346 Received: 14.02.2014 Accepted: 06.03.2014 Published Online: 07.03.2014

Corresponding Author: Adem İlkay Diken, Hitit Üniversitesi Tıp Fakültesi, Kalp ve Damar Cerrahisi, Çamlık Caddesi, Bahçelievler Mahallesi, Çorum, Türkiye. GSM: +905306873315 E-Mail: ademilkay@gmail.com

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Abstract

Aim: We aimed to assess the clinical outcomes of our department of car-diac surgery which was newly introduced in Hitit University Corum Educa-tion and Research Hospital. Material and Method: Between November 2012 and November 2013, a total of 110 open-heart surgeries were performed. Ten out of these (9.1%) were emergency operations for acute ST elevation myocardial infarction Off-pump technique was used in 31 (29.2%) patients and cardiopulmonary bypass was used in 75 (70.8%). A total of 106 patients received coronary artery bypass grafting, 1 received mitral reconstruction, 1 received Bentall procedure, 1 received tricuspid valve repair, 1 received mitral valve replacement, 1 received aortic valve replacement with aortic root enlargement and 1 received aortic supracoronary graft replacement. Results: Hospital mortality occurred in 1 (0.9%) patient. Four patients (3.6%) who were on dual antiaggregants underwent a revision for bleeding on the day of the operation. Morbidities occurred in 3 (2.7%) patients. Atrial fibrilla-tion occurred in 11 (10%) patients and the normal sinus rhythm was achieved by amiodarone. Intraaortic balloon counterpulsation was used in 5 (4.5%) patients. Discussion: The newly introduced cardiac surgery department of the Hitit University Corum Education and Research Hospital, which provides ter-tiary care to a wide rural community, serves with low morbidity and mortality.

Keywords: Cardiac Surgical Procedures; Coronary Artery Bypass Grafting; Surgery Department, Hospital

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Giriş

Kalp cerrahisi diğer cerrahi branşlarına göre yavaş bir gelişim seyri göstermektedir ve bu durumu en iyi Prof. Sherman ifade eder; kalbe olan mesafe birkaç santimetre olsa da, cerrahi bu yolu ancak 2400 yılda kat edebilmiştir [1]. İlk olarak 1896 yılında Ludwig Rhen bir kalp yaralanmasında miyokardı dikerek hastasını kurtarmayı başarmıştır. Bu olay kalp cerrahisinin başlangıcı olarak kabul edilse de, ekstrakorporeal dolaşım kullanılarak yapılan ilk başarılı ameliyat için 57 yıl geçmesi gerekmiş ve Gibbon tarafından 1953’te atrial septal defekt onarımı gerçekleştirilmiştir [1]. Sonrasında bu alandaki gelişmeler giderek hız kazanmıştır.

Ülkemizde kalp cerrahisinin gelişimi dünyadaki gelişmelerle hemen hemen paralel seyretmiştir. 1953 yılında İstanbul’da ilk kapalı mitral komissürotomi yapılırken, ilk ekstrakorporeal dolaşım ile ameliyata ait tebliğ 1963 yılında Hacettepe Üniversitesi tarafından gerçekleştirilmiştir. Sonrasında bu alandaki teknik ve bilimsel gelişmeler, başta Dr. Siyami Ersek Hastanesi ve Türkiye Yüksek İhtisas Hastanesi olmak üzere bazı merkezlerde başarıyla uygulanır hale gelmiştir. Başlangıçta sadece büyük şehirlerde yapılan ameliyatlar, Sağlık Bakanlığı’nın ulusal koordinasyon ve eylem planlarıyla ülkemizdeki birçok il merkezinde başarıyla yapılır hale gelmiştir [2].

Çorum’da yer alan Sağlık Bakanlığı Hitit Üniversitesi Çorum Eğitim ve Araştırma Hastanesi 500 bini aşkın toplam nüfusa sağlık hizmeti vermektedir. Mevcut nüfusa ek olarak coğrafik yakınlıkları nedeniyle Sorgun ve Merzifon gibi büyük çevre ilçelere ait hastalar da bu hizmetten faydalanmaktadır. Ankara ve Samsun gibi iki büyük şehrin tam ortasında yer alan Çorum’a, zamanlamanın çok önemli olduğu kalp hastalıklarının hızlı ve etkin tedavisi açısından Sağlık Bakanlığı tarafından 2011 yılında planlama başlatılarak, 7 ay içinde kalp ve damar cerrahisi merkezi kazandırılmış ve 2012 yılının Kasım ayında ilk kalp cerrahisi ameliyatı gerçekleştirilmiştir. Bu çalışmada kliniğimizde 23.11.2012 ile 26.11.2013 tarihleri arasında yapılan kalp ameliyatları (ilk 110 olgu) değerlendirilmiştir.

Gereç ve Yöntem

Sağlık Bakanlığı Hitit Üniversitesi Çorum Eğitim ve Araştırma Hastanesi kalp ve damar cerrahisi kliniğinde 23.11.2012 ile 26.11.2013 tarihleri arasında 110 açık kalp ameliyatı gerçekleştirildi. Olguların 74’ü erkek (%67.3), 36’sı kadın (%32.7) hastalardan oluşmaktaydı ve yaş ortalaması 59.6±19.4 yıldı. Hastaların preoperatif demografik özellikleri Tablo-1’de yer almaktadır.

Hastalara 4 kişilik kalp ve damar cerrahisi uzman ekibi, 2 kişilik anestezi ve reanimasyon uzman ekibi, 28 hemşire (4 ameliyathane, 11 yoğun bakım, 13 servis), 2 anestezi teknisyeni ve 3 perfüzyonist, 5 yoğun bakım ve 20 servis yatağı ile hizmet sunmaktadır.

Hastaların tüm preoperatif hazırlıkları ve koroner anjiyografi işlemleri hastanemiz bünyesinde gerçekleştirildi. Stabil koroner arter hastalığı olan tüm hastalara ameliyat öncesi güne kadar 300mg/gün asetilsalisilik asit tedavisi verilirken, akut koroner sendrom sırasında veya sonrasında alınan vakalara ise ek olarak ameliyat sabahına kadar klopidogrel 75 mg/gün verilmeye devam edildi. Tüm hastalara preoperatif dönemde anamnez ve fizik muayeneye ek olarak karotis arter Doppler ultrasonografi ve solunum fonksiyonları testi uygulandı.

Tüm hastalara medyan sternotomi uygulandı. Atan kalpte yapılan ameliyatlarda miyokard ve apeks stabilizasyon cihazları (Octopus® ve Starfish®) kullanıldı. Perfüzyonda yapılan ameliyatlarda standart aortokaval kanülasyon tekniğiyle kardiyopulmoner baypasa (CPB) girildi. Kros klemp sonrası antegrad ve aralıklı retrograd kardiyoplejilerle kardiak arest sağlandı. Sağ koroner distal anastomozundan başlanarak tüm distal anastomozlar tamamlandı. 2 vaka dışında tüm hastalarda sol internal mammarian arter (LIMA) in situ olarak kullanıldı. Proksimal anastomozlar “tek klemp” tekniğiyle CPB altında yapıldı. CPB çıkışı ve kanama kontrolünden sonra tüm hastalara epikardiyal pace maker teli konarak sternum çelik sütürlerle “figure-of-eight” şeklinde kapatıldı.

10 hasta (%9.1) ST elevasyonlu miyokard enfarktüsü nedeniyle koroner anjiyografiye müteakip acil olarak ameliyata alındı. 31’i (%29.2) atan kalpte ve 75’i (%70.8) kardiyopulmoner baypas ile olmak üzere toplam 106 hastaya koroner arter baypas greftleme (KABG) yapılırken, 1 mitral onarım (+CABG), 1 Bentall prosedürü, 1 triküspit kapak onarımı, 1 mitral kapak replasmanı, 1 kök genişletmeyle birlikte aort kapak replasmanı ve 1 suprakoroner greft implantasyonu (+CABG) uygulandı. Hastanemizde çocuk kardiyolojisi birimi yer almadığından konjenital kardiyak anomaliler opere edilmedi.

Yoğun bakıma entübe olarak alınan hastalar invazif arteryel monitorizasyon ve yakın hemodinamik takip altında ekstübasyon kriterlerini sağlayınca ekstübe edildi. Yoğun bakımda asgari 2 gün (ortalama 2.2±0.1 gün) takip edilen hastalar göğüs tüpleri alındıktan sonra servise transfer edildi. Servis izlemlerinde sorun yaşanmayan hastalar asgari 4 gece takipten sonra (ortalama 5.3±1.2 gün) postoperatif 10. gün, 1-4-6. ay ve 1.yılda poliklinik kontrolüne çağrılarak taburcu edildi. Tüm hastalara postoperatif dönemde yara bakımı, kişisel hijyen, medikasyonlar, sternum stabilizasyonu, hastaneye başvurma endikasyonları ve iletişim bilgileri hakkında bilgilendirme yapıldı ve bu bilgileri içeren birer kitapçık ve sternum yastığı verildi.

Bulgular

En sık uygulanan kardiyak cerrahi prosedür %68.8 oranla CPB altında KABG cerrahisiydi. Hastaların takip süresi 1-12 ay arasında değişmekte olup ortalama olarak 7.2±4.1 aydır.

Operatif veriler

Perfüzyonda yapılan ameliyatlar için ortalama CPB süresi 89.8±26 dakika, kros klemp süresi ise ortalama 61.1±20.1 dakikaydı. KABG cerrahisi için kullanılan ortalama greft sayısı CPB altında yapılan ameliyatlarda 3.32±1.1, atan kalpte yapılan ameliyatlarda ise 2.27±0.9 olarak saptandı.

Postoperatif veriler

Yoğun bakıma alınan hastalar ortalama 8.21±3.82 saatte ekstübe edildi. Drenaj miktarı KABG cerrahisi geçiren hastalar için ilk günde ortalama 875±325 cc olarak saptandı. 8 (%7.2) hastada inotrop (≥ 5mg/kg/dk dopamin) ilaç kullanıldı. 11 (%10) hastada atriyal fibrilasyon gözlendi ve amiadoron tedavisi ile normal sinüs ritmi sağlandı. Üçü postoperatif süreçte morbidite ve mortalite yaşanan hastalara, 2’si ise preoperatif dönemde akut miyokard enfarktüsü nedeniyle opere edilecek hastalara olmak üzere 5 (%4.5) hastada intraaortik balon pompası (İABP) kullanıldı.

Hastaların ortalama 6.72±3.21 ay takip edildi. Takip sürecinde poliklinik takiplerinde hiçbir hastada mortalite gözlenmedi. 1 hastaya takibinin 6. ayında efor angina nedeniyle yapılan KAG’de greftlerin açık olduğu fakat sirkümfleks koroner arterde yeni bir lezyon oluştuğu görülerek perkütan girişim uygulandı. Bu hasta dışında anginası sebahat eden hasta bulunmamaktadır.

Morbidite

4 (%3.6) hastaya ameliyat günü içerisinde kanama nedeniyle revizyon yapıldı. Bu olguların tümü ikili antiagregan kullanmakta olan akut koroner sendromlu hastalardı. 3 hastada kanama odağı saptanamazken, 1 hastada LIMA yatağından sızıntı şeklinde yaygın kanama olduğu görüldü. Hiçbir hastada postoperatif süreçte hastane enfeksiyonu gözlenmedi. İkisi erken dönemde, bir ise postoperatif ilk aydan sonra olmak üzere 3(%2.7) hastada morbidite gözlendi. Bu hastalar;

1. Hasta: 69 yaşında kadın, allerjik astım ve atopik dermatit öyküsü olan bu hastada postoperatif dönemde inferiyor derivasyonlarda ST elevasyonu gelişmesi üzerine İABP eşliğinde koroner anjiografi (KAG) yapıldı. Sağ koroner arter distalinde plak rüptürü gözlenmesi üzerine stent takıldı. KAG sonrası akut respiratuar distres sendromu tablosu gelişen hastaya non-invazif mekanik ventilasyon ve solunum fizyoterapisi uygulandı. Hasta üç haftalık hastane takibi sonrasında genel sağlık durumu yerinde olarak taburcu edildi. Halen poliklinik kontrollerine gelmektedir.

2. Hasta: 69 yaşında erkek, 3 damar hastalığı nedeniyle opere edilen ancak porselen asendan aorta ile karşılaşılması nedeniyle aşamalı revaskülarizasyona karar verilerek atan kalpte tekli KABG yapılan hasta postoperatif dönemde düşük kardiyak debi sendromuna girmesi üzerine İABP eşliğinde KAG’ye alındı. Perkütan olarak revaskülarizasyon sağlanamaması üzerine acil olarak femoral arterden CPB hazırlığı yapılarak atan kalpte sağ internal mammarian arter (RIMA) ile sağ posterior desendan arter anastomozu yapıldı. Postoperatif dönemde kliniği düzelen hasta taburcu edildi ve halen poliklinik takibindedir.

3. Hasta: 59 yaşında erkek, acil KABG cerrahisine müteakip rutin takip sonrasında taburcu edilen fakat evde antidepresan ilaç kullanımına bağlı ciddi hiponatremi (Sodyum:109 mmol/Litre) ile hastaneye başvuran hastada non-kardiyak nedenle pulmoner ödem gelişti ve bir aylık yoğun bakım takibi sonrasında taburcu edilmiştir ve sağlıklı bir şekilde poliklinik takiplerine gelmektedir.

Mortalite

Bir hastada (63 yaşında, erkek) mortalite gözlendi. 4 damarına KABG yapılan hastaya CPB çıkışında protamin verilmesine müteakip alerjik reaksiyon gelişti. Geçici hipotansiyon ve bradikardi gelişen hastaya intravenöz kortikosteroid ve antihistaminik yapıldı ve hemodinamisi düzeldi. Yoğun bakıma alınan hastada postoperatif 30. dakikada önce hipoksi, ardından da bradikardi ve hipotansiyon gelişmesi üzerine yatak başında revizyona alındı. CPB’a girildi. Tüm greftlerin açıklığı prob ve palpasyonla kontrol edildi. Akciğerlerin sertleştiği ve renginin kızardığı gözlenen hastanın sol ventrikül fonksiyonları normaldi. CPB’tan hipoksi nedeniyle çıkarılamayan hastaya veno-arteryel ekstra korporeal membran oksijenatörü (ECMO) takıldı. Operasyon sonrası açık sternumla takip edilen hasta 16. saatte dissemine intravasküler koagülasyon ve vasküler kollaps gelişmesi üzerine exitus oldu.

Tartışma

Günümüzde kalp ve damar hastalıkları orta ve ileri yaş gurubunda en önemli ölüm nedeni olup dünyadaki ölümlerin %30’unu teşkil etmektedir [3,4]. Ülkemizde koroner kalp hastalığının yaygınlığı %4-5, sıklığı %0.3-0.4 arasında değişmektedir [3]. Önemli bir morbidite ve mortalite sebebi olan kardiyovasküler hastalıkların tedavisinin ivedilikle yapılması gerekmektedir. Özellikle akut miyokard enfarktüsünde ilk 4-6 saatte yapılabilecek invazif tedavi hasta hayatı açısından önem arz etmektedir. Hemodinamik instabilite olan ve acil invazif müdahale gerektiren durumlarda transferler esnasında ölümler olabilmektedir. Kalp ve damar hastalıklarında yerinde tedavi ile kısa sürede sağlık hizmetine ulaşılması sağlanmakta, transferler ve sonuç olarak hasta ve kurumlar açısından giderler ve ölümler azalmaktadır. Hastanın kontrole gidip gelmesi ve ilgili hekimine ulaşmasında rahatlık olmakta ve hastaların sosyal ve çalışma hayatları sekteye uğramamaktadır.

Ülkemizde nitelikli sağlık hizmetinin yaygınlaştırılması için yeni bölgesel merkezler kurulmakta, var olan merkezler üniversite ile afiliye edilerek akademik yapısı güçlendirilmekte ve mevcut hastanelerde bölgenin ihtiyacına göre yeni bölümler hizmete sunulmakta veya bölümlerin alt yapısı güçlendirilerek verilen hizmetin kalitesi arttırılmaktadır [5,6,7]. Çorum devlet hastanesi Ağustos 2012’de Hitit Üniversitesi ile afiliye olup ismi T.C. Sağlık Bakanlığı Hitit Üniversitesi Çorum Eğitim ve Araştırma Hastanesi şeklinde değiştirilmiştir. Hizmet veren Kardiyoloji ve Kalp ve Damar Cerrahisi kliniklerinin alt yapısı güçlendirilerek koroner anjiyografi ve açık kalp cerrahisi yapabilecek hale getirilmiştir. Hastanemizde de açık kalp cerrahisi uluslararası standartlarda (%0.9 mortalite ve % 2.7 morbidite) ve başarılı bir şekilde yapılmaktadır. Kliniğimizde ilk aylarda 5-6 olan ameliyat sayısı bir yıllık süre içerisinde kliniğin adaptasyonu ve halkın ilgisi ile artarak ayda 20 ameliyata kadar çıkmıştır. Üniversite çatısı altında imkanları artan kliniğimizde kalp cerrahisine ek olarak yıllık 1000 civarında periferik arter ve venöz cerrahi işlemi de yapılır hale gelmiştir. Branşımızı ilgilendiren hasta sevkleri büyük ölçüde azalarak hasta mağduriyeti, ekonomik kayıplar ve en önemlisi olan zaman kaybı asgari düzeye indirilmiştir. Bu zaman zarfında 3-4 ayda bir yerel medyadan kliniğin hizmetleri hakkında bilgi verilerek kamuoyu aydınlatılmıştır.

Kliniğimizde açık kalp ameliyatlarına başlamadan önce ameliyathane ve yoğun bakımdan hemşireler eğitim için Türkiye Yüksek İhtisas Hastanesi’ne 3 aylık eğitim programına gönderildi. Klinik içindeki hemşire ve personele seminerler verildi. Ulusal sertifikasyon programı kriterlerini karşılayan perfüzyonistlerle gerçek vaka şartlarına yakın simulasyonlar yapıldı [8]. Açık kalp cerrahisinin bir ekip işi olduğu ve ekipteki her bireyin yaptığı işin önemli olduğu özellikle vurgulandı. Açık kalp cerrahisi öncesi klinik içi eğitimlerimiz ameliyatlardan sonra da devam etmiştir. Elde edilen başarılı sonuçlarda sürekli personel eğitiminin büyük payı bulunmaktadır. Ayrıca, kliniğimizde yoğun bakım takipleri ve nöbetler henüz asistan alımı olmadığı için hastanın ameliyatına giren cerrah tarafından yapılmaktadır. Bu durumun, cerrahlar için yoğun bir çalışma programını beraberinde getirse de, morbiditeye olumlu anlamda katkı yaptığına inanmaktayız.

Günümüzde koroner baypas cerrahisine giden hastaların ileri yaşta olması ve diyabet, kronik obstruktif akciğer hastalığı (KOAH), kronik böbrek yetmezliği gibi ek komorbit hastalıkların olması CPB kullanımının riskini arttırmaktadır. 31 hastaya atan kalpte koroner arter baypas cerrahisi yapılmıştır. Bu hastalardan 15’inde KOAH ve 6’sında ileri yaş nedeniyle atan kalpte KABG tercih edilmiştir. Hastalarımızdan 3 tanesine kombine girişim yapılmıştır. Bu hastalarda mortalite veya morbidite görülmemiştir.

Kardiyak cerrahi geçiren hastalarda sternal yara enfeksiyonu oranı %1.0 ile %8.6 arasındadır [9]. Kliniğimizde sternal yara enfeksiyonu gözlenmezken, poliklinik takibi sırasında 2 hastada safen insizyon yerinde lokal enfeksiyon gözlendi ve uygun antibiyotik ve lokal yara bakımı ile tedavi edildi. Enfeksiyon oranımızın düşük olmasında birimimizin dünya standartlarındaki teknolojiyle yeni kurulmuş olması, ameliyathane ve yoğun bakımda sık partikül sayımının yapıldığı laminar akımın olması, hasta başına bir hemşire düşecek şekilde hemşire çalışma düzeninin yapılması ve tüm yardımcı sağlık personelinin bire bir eğitimden geçirilmesinin etkisinin büyük olduğunu düşünmekteyiz.

Merkezimizde 1 ameliyathane, 5 yataklı yoğun bakım ve 36 yataklı servis ile Çorum ve çevre halkına kaliteli ve üstün hizmet vermeyi sürdürmekteyiz. Artan vaka çeşitliliği ve büyüyen hasta sayımızla ülkemiz ve dünyadaki saygın kalp ve damar cerrahisi merkezlerinin konumuna ulaşmayı hedeflemekteyiz.

Çıkar Çakışması ve Finansman Beyanı

Bu çalışmada çıkar çakışması ve finansman destek alındığı beyan edilmemiştir.

Kaynaklar

1.Hurt R, editor. The History of Cardiothoracic Surgery from earliest times. London: The Parthenon Publishing Group; 1996. p 25-44

2. Kervan Ü, Özatik MA, Bayraktar G, Şener E, Çağlı K, Yekeler İ et al. Distribution and service quality of the cardiovascular surgery clinics in Turkey. Türk Göğüs Kalp Damar Cer Derg 2011;19(4):483-9.

3. T.C. Sağlık Bakanlığı Temel Sağlık Hizmetleri Genel Müdürlüğü Türkiye Kalp Ve Damar Hastalıklarını Önleme Ve Kontrol Programı Birincil, İkincil ve Üçüncül Korumaya Yönelik Stratejik Plan ve Eylem Planı (2010-2014), Ankara, 2010

4. Buğan B, Çelik T. Koroner Arter Hastalığı Risk Faktörleri. J Clin Anal Med 2014;5(2): 159-63.

5. Büyükateş M, Turan SA, Kandemir Ö, Tokmakoğlu H. Zonguldak Karaelmas Üniversitesi Uygulama ve Araştırma Hastanesi’nde açık kalp cerrahisi: İlk 170 olgunun değerlendirilmesi. Türk Göğüs Kalp Damar Cer Derg 2007;15(1):51-4.

6. Yasım A, Aşık R. Yeni Bir Açık Kalp Cerrahisi Merkezi: Kayseri Devlet Hastanesi’nin 3 Yıllık Deneyimi. Türk Göğüs Kalp Damar Cer Derg 2004;12(1):22-5.

7. Köksal C, Sarıkaya S, Özcan V, Zengin M, Meydan B, Helvacı A et al. SSK Süreyyapaşa Hastanesi’nde Açık Kalp Cerrahisi: İlk 100Vaka. Türk Göğüs Kalp Damar Cer Derg 2002;10:264-6.

8. Bilgili A, Şahin T, Güler A, Tatar H. Dünyada ve Türkiye’de Perfüzyonist Eğitimi. J Clin Anal Med 2010;1(3):60-2.

9. Bellchambers J, Harris JM, Cullinan P, Gaya H, Pepper JR. A prospective study of wound infection in coronary artery surgery. Eur J Cardiothorac Surg 1999;15(1):45-50.

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Adem Ilkay Diken, Adnan Yalcinkaya, Seyhan Yilmaz, Eray Aksoy, Emrah Ereren, Yasemen Hobek Aydin, Mustafa Paç, Kerim Çağlı. Heart Surgery Experience in Hitit University Faculty of Medicine Corum Research and Training Hospital: First Year Results. J Clin Anal Med. 2015;6(6):679-682

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Case Report

A Case with Partial 9p Trisomy and Speech Impairment

Mehmet Elbistan, Akın Tekcan, Şengül Tural, Nevin Karakuş, Nurten Kara

Department of Medical Biology and Genetic, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey

DOI: 10.4328/JCAM.1226 Received: 20.07.2012 Accepted: 16.09.2012 Publihed Online: 17.09.2012

Corresponding Author: Akın Tekcan, Ondokuz Mayis University, 55139 Kurupelit Samsun, Turkey. GSM: +905055719646 E-Mail: akintekcan@hotmail.com

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Abstract

In this study, we aimed to discuss the relationships between his phenotypic anom-alies and der(15), ish t(9;15)(p12;q10) balanced reciprocal translocation entity that determined from 5 year old male child who referred to our laboratory for cytogenetic analysis. He has complaints speech impairment and growth retarda-tion. And whose family has no phenotypic anomalies. After assessing the case’s pedigree, the preparations obtained from case and relatives using peripheric blood culture method and evaluated with GTG banding. Cytogenetic analyses of her father and mother revealed normal karyotypes. We convinced that the bal-anced reciprocal translocation may be as a result of de novo mechanism. So, we discussed relationship between phenotypic anomalies and genetic characteristics of case in the light of the literature.

Keywords: Chromosomal Anomaly; Partial Trisomy; Speech Impairment

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Introduction

Humans are characterized by an extraordinarily complex system of their verbal communication. There are two types of human communication including speech and language. Speech generally defines to the mechanical direction of verbal communication. Making sentences, sentence defining with sound, fluency are necessary qualifications for speech. Language is a complex function that are making meaningful words within the rules, making new words, using together of words, allowing the construction of word combinations in specific situations. The barriers of human communication is categorized as language and speech impairment. Speech impairments are include sentence building problems, speech fluency problems and dyspraxia [1]. Developmental speech and language disorders play an important role within childhood diseases in spite of different phenotypes based on heterogeneous factors. Speech and language development disorders is identified five categories [2]. These include mixed receptive-expressive language disorder, expressive language disorder, phonological disorder, stuttering and communication disorders [3]. The most of language and speech disorders are seen to accompanied other pathological features in spite of recognized as clinically. While the approximately 15% of children with persistent speech impairment have development a language disorders. Approximately %5 of children with speech and language disorders have speech difficulty at the same time [3,4].

Trisomy 9p is one of the autosomal aneuploidies that has long survival. The clinical findings in patients with trisomy 9p is directly related to size of duplicated chromosomal material. Trisomy 9p syndrome is defined to clinically and the most significant finding of it’s is craniofacial dysmorphism [5]. In addition, it is reported that neurological problems, speech and language disorders are seen in cases with trisomy 9p [6-8].

Case Report

Cytogenetic analysis of case, who referred to our laboratory with speech impairment (such as verbal dyspraxia and speech fluency problems) and growth retardation, showed that has been a carrier of balanced reciprocal translocation (46,XY, der(15), ish t(9;15)(p12;q11.2) (Figure 1, 2). Cytogenetic analyses of his parents, two sisters and two brothers revealed normal karyotypes (Figure 3). Karyotype analyses of cases were made from their peripheral blood lymphocytes by standard method. Fifty metaphases had been prepared with GTG banding method for each patient was analyzed. Thirty metaphases were karyotyped. Karyotypes were described by using ISCN 2005 standard nomenclature of human chromosomes. In addition, fluorescence in-situ hybridization (FISH) analysis was performed the case.

Discussion

Genetic factors were determined to have effects on formation of language and speech abnormalities. By the studies searching the genetic factors that take a part in the formation of language and speech abnormalities; ıt was understood that the formation of language and speech abnormalities in both of the twins were more common in monozygotic twins than dizygotic twins. The reason of the appearance of language and speech abnormalities in monozygotic twins more commonly than dizygotic twins was reported to origin from familial accumulation in addition to similar genetic factors in monozygotic twins [9-11]. Environmental factors interacting with genetic factors were shown to have influence on the formation of language and speech abnormalities, so, it has a multifactorial inheritance [3,12,13]. Although genetic factors were shown to have effect on language and speech abnormalities, its pathology has not been understood yet [3].

In a report published by Rossi et al., after the evaluation of the case with delayed development, microcephaly, micrognathy, brachycephalic, bulbous nose, downturned oral commissures, malformed ears and feet, and hypotonia; one of the parents of the case was estimated to be carrier of t(9;15), so the case had language and speech abnormalities because of partial trisomy 9p [8]. In another report published by de Pater et al., similar findings with Rossi et al. were observed in a partial trisomy 9p case whose mother was carrier of t(9;12) [6]. By another study which was reported by Hauge et al. with 10 cases of 9p deletion, it was reported that there were genes associated with language and speech development, neurologic development, so language and speech delay may occur as result of copy number variations in these regions [7]. The results of Rossi et al., de Pater et al. and Hauge et al., presented that various regions in p arm of the chromosome 9 carry important genes for the development of language and speech and it was understood that the findings of our case were in concordance with the literature reports. As a result, our examinations showed that partial 9p trisomy der (15) t(9;15)(p12;p11,2) karyotype occured de novo. Though the formation mechanisms of the translocations are not exactly known. It is believed that the recombination is basic mechanism. Phenotypical findings of this patient with partial trisomy 9p discussed with other trisomy 9p cases in the literature. In the present case speech disorders were observed as a result of 9p trisomy. To protect the health of future generations; importance of prenatal diagnosis and genetic counseling were emphasized in this study.

Competing interests

The authors declare that they have no competing interests.

References

1. Kang C, Drayna D. Genetics of Speech and Language Disorders. Annu Rev Genomics Hum Genet 2011;12:1-20.

2. Harel S, Greenstein Y, Kramer U, Yifat R, Samuel E, Nevo Y, et al. Clinical characteristics of children referred to a child development center for evaluation of speech, language, and communication disorders. Pediatr Neurol 1996;15(4):305-11.

3. Newbury DF, Monaco AP. Genetics advances in the study of speech and language disorders. Neuron 2010;68(13):309-20.

4. Shriberg LD, Tomblin JB, McSweeny JL. Prevalence of speech delay in 6-year-old children and comorbidity with language impairment. J Speech Lang Hear Res 1999;42(6):1461-81.

5. Temtamy SA, Kamel AK, Ismail S, Helmy NA, Aglan MS, El Gammal M, et al. Phenotypic and cytogenetic spectrum of 9p trisomy. Genet Couns 2007;18(1):29-48.

6. de Pater JM, Ippel PF, van Dam WM, Loneus WH, Engelen JJ. Characterization of partial trisomy 9p due to insertional translocation by chromosomal (micro) FISH. Clin Genet 2002;62:482-7.

7. Hauge X, Raca G, Cooper S, May K, Spiro R, Adam M, et al. Detailed characterization of and clinical correlations in ten patients with distal deletions on chromosome 9p. Genet Med 2008;10(8):599-611.

8. Rossi NF, Gatto AR, Cola PC, Souza DH, Moretti-Ferreira D, Giacheti CM. Oropharangeal dysphagia and language delay in partial trisomy 9p:case report. Genetics and Molecular Research 2009;8(3):1133-8.

9. Bishop DV. The role of genes in the etiology of specific language impairment. J Commun Disord 2002;35(4):311-28.

10. Felsenfeld S, Kirk KM, Zhu G, Statham DJ, Neale MC, Martin NG. A study of the genetic and environmental etiology of stuttering in a selected twin sample. Behav Genet 2000;30(5):359-66.

11. Hayiou-Thomas ME. Genetic and environmental influences on early speech, language and literacy development. J Commun Disord 2008;41(5):397-408.

12. Kang C, Riazuddin S, Mundorff J, Krasnewich D, Friedman P, Mullikin JC, Drayna D. Mutations in the lysosomal enzyme-targeting pathway and persistent stuttering. N Engl J Med 2010;362(8):677-85.

13. Newbury DF, Winchester L, Addis L, Paracchini S, Buckingham LL, Clark A, et al. CMIP and ATP2C2 modulate phonological short-term memory in language impairment. Am J Hum Genet 2009;85(2):264-72.

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Mehmet Elbistan, Akin Tekcan , Sengul Tural, Nevin Karakus, Nurten Kara. A Case with Partial 9p Trisomy and Speech Impairment. J Clin Anal Med. 2015;6(6):796-798

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Chemical Pneumonitis and Acute Dyspnea Following Exposure to Tribenuron Methyl

Servet Kayhan, Atilla Guven Atici, Nurhan Koksal, Davut Aydin

University of Ondokuz Mayıs, School of Medicine, Department of Pulmonary Medicine, Samsun, Turkey

DOI: 10.4328/JCAM.1242 Received: 05.08.2012 Accepted: 03.09.2012 Published Online: 03.09.2012

Corresponding Author: Servet Kayhan, Ondokuz Mayıs University, School of Medicine, Department of Pulmonary Disease, Samsun, Turkey. T. :+905326717174 E-Mail: kayhanservet@gmail.com

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A previously healthy 48-year-old man admitted to our clinic with an acute dys-pnea and pneumonia like illness following use of a tribenuron methyl containing herbicide agent. Exposure was inhalational in nature during agricultural spray-ing without implementing the precautions. The patient completely recovered by methyl prednisolone, inhaler corticosteroid and long acting beta-2 agonist com-bination therapy. For this case, the differential diagnosis of chemical pneumonitis and acute dypnea from inhalational exposure to herbicide and clinical findings are discussed.

Keywords: Hypersensitivity; Inhalation; Pneumonitis; Toxicity

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Introduction

Herbicide and pesticide poisonings among farmers and occupational workers in developing countries are alarming primarily because of unsafe applications and handling practices [1]. WHO estimated approximately 20000 deaths among workers from exposure to agricultural chemicals every year, the majority in developing countries [2]. Tribenuron methyl (Vhashi™ 75 DF, China) is a member of the sulfonylurea herbicide characterised by low application rates and high phytotoxicity. It is used for weed control in cereals and other crops and are highly active against a wide range of broad leaved weeds [3]. It has been registered in many countries including Turkey. However, its toxic effects on humans are not well known and reported as unharmful to human health previously [4]. We describe a case of chemical pneumonitis following use of a herbicide agent containing tribenuron methyl. To our knowledge, pulmonary injury associated with use of tribenuron methyl inhalation has not been reported.

Case Report

A forty eight year old, previously healthy farmer male referred to our clinic with an initial diagnosis of community acquired pneumonia and acute asthma like disease. His complaints were dyspnea, cough with purulent sputum and high fever ongoing for a week. He also smoked 1.5 packs of cigarettes a day for 20 years. There was a history of 2 days working in agriculture and exposing to a herbicide, tribenuron methyl, by inhalatory route without using any protective mask. A detailed composition obtained from the manufacturer was 75% tribenuron-methyl formulated as [Methyl 2-[4-methoxy-6 methyl-1,2,3-triazin-2-yl (methyl) carbamoylsulfamoyl] benzoate]. His heart rate was 92 beats/min; blood pressure 120/70 mmHg; respiratory rate 23 breaths/min; and pulse oximetry indicated 96% saturation, fever was 37.1 centigrade degrees, Bilateral wheezing was heard during oscultation. Pathcy infiltrations were determined in chest x-ray graph. Thoracic computed tomography revealed bilateral mediastinal lymphadenopathies, diffuse and irregular ground glass opacities, fibrotic changes and multiple subpleural nodules (figure 1). Spirometric results were documented during admission to our clinic as follows; FVC: 3.08 liter (68.9%), FEV1: 2.58 liter (70.6%), FEV1/FVC: 83.8%, PEF: 6.28 liter/min (72.3%) and FEF 25-75 value was 2.69 (70.5%) liter. Bronchial lavage and transbronchial biopsy was performed from the inferior segment of the lingula having hyperemic and edematous mucosa with the aim of fiberoptic bronchoscopy. Lymphocytic infiltration and granulomatous reactions were reported by cytologic examination of the specimens. The patient was treated by methyl prednisolone (1mg/kg), budesonide (inhaler corticosteroid, 400 microgram/day) and formoterol (long acting beta-2 agonist, 24 microgram/day). Clinical, spirometric and radiological improvements (figure 2) were achieved and his asthmatic symptoms are almost totally regressed after two weeks of the therapy. Chest x-ray graph and pulmonary functions of the patient were detected as completely normal during second control after two months from exposure.

Discussion

Herbicides and pesticides are used extensively throughout the world and are playing a pivotal role in meeting the food demand of escalating population. The three major routes of entry to body for chemicals include contamination of the skin, lungs and the gut. The respiratory tract provides a very efficient surface for the absorption of substances, whether they are in the form of vapors, particles or droplets. Herbicide inhalations may cause subacute dyspnea and pneumonitis as presented here but this patient has some clinical similarities with hypersensitivity pneumonitis and reactive airway dysfunction syndrome (RADS). Exposure to chemicals may cause different clinical tables changing from mild irritation to severe parenchymal destruction in respiratory tract based on chemical structure of exposed material, duration and severity of exposure and sensitivity of the persons [1;2;5;6].

To summarize the case history, the patient experienced immediate irritant symptoms following use of a tribunuron methyl containing herbicide. Within 24 hours, he was documented to have cough, chest pain, blurry vision, vertigo and a diffuse irregular infiltrate on chest radiography. After 2 more days while on intravenous antibiotic therapy, his condition worsened with the development of dyspnea requiring oxygen support and bronchodilatator therapy than the patient was referred to our clinic which is a tertiary hospital. Early bronchoscopy (day 4) showed the presence of diffuse bronchiolitis and granulomatous reactions. He recovered completely after treatment. Although it is possible a biological or chemical agent other than herbicide caused the patient’s pathology, herbicide remains the most likely causative factor for the patient was healthy and not afflicted by any pulmonary disease previously. Testing and cultures for a microbiological cause were negative, and he did not respond to antiobiotic therapy. Physical examination is unlikely to be helpful in establishing the diagnosis of the patient: bibasilar crackles and wheezing is heard on auscultation of the lung. It does not show evidence of allergy such as prick test positivity, high IgE levels, and eosinophilia. Routine laboratory tests and specific serum precipitating antibodies are unhelpful to establish the diagnosis in present subject. Spirometric tests demonstrate restrictive changes with impaired DLCO being neither specific nor diagnostic for hypersensitivity pneumonitis. Arterial blood gases and diffusion values can be impaired in the early stage of diffuse parenchymal lung diseases [7].

The findings of patchy pneumonic infiltrations on chest x-ray graphy, ground glass appearence in high resolution thorax computed tomography, airway obstructions followed by exogenous exposure to toxic gas, lymphocytic infiltration and granulomatous reaction are same in subacute form of hypersensitivity pneumonitis and resembles RADS [7].

Hypersentivity pneumonitis or extrinsic allergic alveolitis is an immunologically induced lung disease caused by repeated inhalation of agents in sensitized individuals and a rare cause of diffuse parenchymal lung disease [8]. The diagnosis of hypersensitivity pneumonitis can be established by clinical, radiological and bronchoalveolar lavage fluid findings. The characteristic pattern of the high resolution computed tomography is the presence of ground glass shadowing, bilateral micronodular infiltrates in diffuse parenchymal or interstitial lung diseases. Transbronchial biopsy by fiberoptic bronchoscopy or open lung biopsy may be required in patients with symptoms of insidious onset and that cannot be clearly related to any particular exposure. It may present with an extensive variety of clinical abnormalities depending on the nature of the inhaled antigens, microorganisms, animal proteins, haptens formed on endogenous proteins or chemicals [9]. The most characteristic cell profile in bronchoalveolar fluid is of a lymphocytic alveolitis with a predominance of CD8 (+) T cells. RADS is defined as the persistant airway obstruction following an acute exposure to irritants such as chemicals, gases or heavy dusts. Inhalations cause acute and severe injury in airways. Symptoms of cough, dyspnea and wheezing starts suddenly, shows persistent character ongoing several years [6]. But spirometric and radiologic results of our patient were normal after the treatment.

In an experimental study it is stated that therapy with terbutaline and budesonide combination was associated with significant improvement in PaO2 and lung compliance, as compared with placebo or treatment with either drug alone in acute chlorine gas induced lung injury [10]. We treated our patient with formoterol and budesonide combination and systemic corticosteroids as in acute asthma. The final results of respiratory function tests and radiologic controls showed the pulmonary improvements.

It can be hypothesized that the toxicity of inhaled herbicides may trigger severe inflammatory reactions and releasing some mediators in respiratory tract and cause a transient airway obstruction and interstitial lung disease. Subsequently, these reactions may cause clinical illness such as pneumonitis and bronchoconstriction or asthma like disease.

As a result, herbicide toxicity should be considered in the differential diagnosis of acute dyspnea and community acquired pneumonia in patients who work in agricultural occupations and a more careful history taking is important in diagnosis.

Competing interests

The authors declare that they have no competing interests.

References

1. Kesavachandran CN, Fareed M, Pathak MK, Bihari V, Mathur N, Srivastava AK. Adverse health effects of pesticides in agrarian populations of developing countries. Rev Environ Contam Toxicol 2009:200;33-52.

2. Kishi M, Hirschhorn N, Ojajadisastra M, Satterfee LN, Stroman S, Dilts R. Relationship of pesticide spraying to signs and symptom in Indonesian farmers. Scand J Environ Health 1995:21(2);124-33.

3. Andersen SM, Hertz PB, Holst T, Bossi R, Jacobsen CS. Mineralisation studies of 14C-labelled metsulfuron-methyl, tribenuron-methyl, chlorsulfuron and thifensulfuron-methyl in one Danish soil and groundwater sediment profile. Chemosphere 2001:45(6-7);775-82.

4. Hashmi I, Khan A. Adverse Health Effects of Pesticides Exposure in Agricultural and Industrial Workers of Developing Country. In: Margarita Stoytcheva, editor. Pesticides-The Impacts of Pesticide Exposure. Croatia: In Tech Rijeka; 2011.p.155-78.

5. Sertoğullarından B, Bora A, Sayır F, Ozbay B. Hydrocarbon pneumonitis; clinical and radiological variability. Doi: 10.4328/JCAM.869 published online 20.01.2012.

6. Robert PD, David AS. Acute and Chronic Responses to Toxic Inhalations. In: Fishman AP, editor. Fishman’s Pulmonary Diseases and Disorders. New York: Mc Graw-Hill Book Company; 1998. p. 993-1009.

7. Kupeli E, Karnak D, Kayacan O, Beder S. Clues for the differential diagnosis of hypersensitivity pneumonitis as an expectant variant of diffuse parenchymal lung disease. Postgrad Med J 2004; 80(944): 339–45.

8. American Thoracic Society/European Respiratory Society. International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med 2002;165(2): 227–304.

9. Zacharisen MC. Idiopathic interstitial pneumonia: are we missing hypersensitivity pneumonitis? Ann Allergy Asthma Immunol 2002;88(1): 4–6.

10. Wang J, Zhang L, Walther SM. Administration of aerosolized terbutaline and budesonide reduces chlorine gas-induced acute lung injury. J Trauma 2004;56(4): 850-62.

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Servet Kayhan, Atilla Guven Atici, Nurhan Koksal, Davut Aydin. Chemical Pneumonitis and Acute Dyspnea Following Exposure to Tribenuron Methyl. J Clin Anal Med. 2015;6(6):793-795

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Idiopathic Sustained Epicardial Ventricular Tachycardia Originating from the Great Cardiac Vein

Barış Buğan 1, Turgay Çelik 2, Hasan Kutsi Kabul 2, Erkan Yıldırım 2, Atila İyisoy 2

1 Malatya Military Hospital, Cardiology Service, Malatya, 2 Gulhane Military Medical Academy, Department of Cardiology, Ankara, Turkey

DOI: 10.4328/JCAM.1256 Received: 14.08.2012 Accepted: 26.08.2012 Publihed Online: 27.08.2012

Corresponding Author: Barış Buğan, Malatya Military Hospital, Cardiology Service, Malatya, Turkey. T.: +90 4223365434 F.: +90 4223362043 E-Mail: bbugan@hotmail.com

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Ventricular tachycardia arising from the great cardiac vein is a rarely encountered entity. Prevalence, characteristics of electrocardiogram, common sites of ventri-cular tachycardia origin around the coronary sinus, or efficacy of therapy with ra-diofrequency catheter ablation of this idiopathic ventricular tachycardia is unk-nown. This case report emphasizes the electrophysiological characteristics of idi-opathic ventricular tachycardia arising from the great cardiac vein.

Keywords: Ablation; Great Cardiac Vein; Idiopathic; Ventricular Tachycardia

Full Text

Introduction

Idiopathic ventricular tachycardia (VT) and premature ventricular contractions (PVC) mainly originate from the right ventricular outflow tract (RVOT). Idiopathic VT/PVCs originating from the great cardiac vein constitute only a small number of cases. There is little data regarding the prevalence, ECG characteristics, and common sites of tachycardia origin around the coronary sinus and especially its branches, and efficacy of radiofrequency (RF) catheter ablation of these cases. Herein we report a case of symptomatic, sustained idiopathic VT originating from the great cardiac vein in a otherwise healthy female.

Case Report

A 32-year-old female was first admitted to another hospital with palpitation, and syncope two months ago. Electrophysiological study (EPS) and radiofrequency ablation was performed from the left aortic valve cusp (AVC) due to epicardial ventricular tachycardia, but she was admitted to our hospital with the same symptoms. Her physical examination was unremarkable. 12-lead electrocardiogram (ECG) obtained during the clinical tachycardia revealed sustained VT with right bundle branch block (RBBB) QRS morphology and a rightward axis (Figure 1). Echocardiography revealed a normal examination with a global ejection fraction of 68% and no chamber enlargement or valve disease. Magnetic resonance imaging (MRI) showed normal cardiac structures. EPS was performed. During mapping of the coronary sinus in EPS, pace mapping and the earliest ventricular activation site revealed that the origin of the tachycardia was the great cardiac vein. The intracardiac electrocardiographic recordings showed that the ventricular activation was 21 ms before QRS onset (Figure 2). Several RF energy applications (50 ºC, 50 W) were delivered at the site where earliest ventricular activation was recorded. After the procedure, tachycardia completely disappeared and spontaneous or clinical VT/PVCs were not induced by isoproterenol at the end of 20 minutes of monitoring. The electrocardiograms obtained two days after the procedure were normal. Patient was discharged from the hospital without any medication. The patient has remained completely asymptomatic 12 months after the procedure.

Discussion

Idiopathic VT/PVCs may be classified by using several criteria including mechanism, location, and response to pharmacologic agents. Main classification groups are as follows: outflow tract VT, idiopathic left VT, and automatic VT. Outflow tract region describes the RV region between the pulmonary and tricuspid valves, the basal left ventricle including the outflow tract under the aortic valve, the aortic cusps, and the basal left ventricular (LV) epicardium. Most idiopathic VT/PVCs arise from RVOT [1].

ECG is an important guide to rapidly locate the origin of the tachycardia and plan the optimal catheter ablation before the patient is brought to the electrophysiology laboratory [1;2]. Ratio of the idiopathic outflow tract VT/PVCs originating from the epicardium are 9–13% [1-3]. The ECG characteristics of these tachycardia cases are described as follows: significantly greater R wave amplitude in the inferior leads, an S wave in lead I as part of an rS or QS pattern, and greater Q wave amplitude in aVL compared with aVR (ratio >1.4) [1-3]. In this case, ECG characteristics have shown almost the same criteria. In addition, a Q wave in lead I more commonly identify VT from an epicardial origin compared with an endocardial site [1]. Daniels et al [3] reported that a delayed precordial maximum deflection index ≥0.55 confidently localized VT to the epicardium with a sensitivity of 100% and a specificity of 98%.

Medical therapy and ablation are the options for management of these arrhythmias. Frequency and severity of symptoms play a critical role in determining the treatment strategy. Ablative therapy of epicardial VT/PVCs includes percutaneous and transthoracic epicardial approaches [1;3]. Ablation via percutaneous approach is performed from the AVC or coronary venous system and is feasible and often effective in selected patients. The majority of the patients can be successfully treated by this procedure. The transthoracic epicardial approach is recommended in cases in which standard ablation approaches have failed [3]. We performed ablation via the great cardiac vein because the previous ablation attempt via AVC in another hospital had failed. Meininger et al. [4] and Kaseno et al [5] reported successful ablation in patients with drug-refractory nonsustained VTs and PVCs originating from the great cardiac vein, as in our case.

Complications during ablation using CS and its branches consist of venous stenosis, vein rupture, venous thrombosis, and damage to adjacent coronary arteries with resultant stenosis [4;5]. Careful monitoring of catheter position may provide protection from all these complications.

Although idiopathic VT and PVCs mainly originate from the RVOT, uncommon sites of origin are seldom encountered. If the idiopathic VT/PVCs are not localized in the most common origin, epicardial foci including coronary sinus and its branches should be sought by pace-mapping. Careful analysis of the ECG before the procedure will facilitate the electrophysiological study in these patients.

Competing interests

The authors declare that they have no competing interests.

References

1. Latif S, Dixit S, Callans DJ. Ventricular arrhythmias in normal hearts. Cardiol Clin 2008 Aug;26(3):367-80.

2. Tada H, Nogami A, Naito S, Fukazawa H, Horie Y, Kubota S, et al. Left ventricular epicardial outflow tract tachycardia: a new distinct subgroup of outflow tract tachycardia. Jpn Circ J 2001;65(8):723-30.

3. Daniels DV, Lu YY, Morton JB, Santucci PA, Akar JG, Green A, et al. Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of Valsalva: electrophysiological characteristics, catheter ablation, and identification from the 12-lead electrocardiogram. Circulation 2006;113(13):1659–66.

4. Meininger GR, Berger RD. Idiopathic ventricular tachycardia originating in the great cardiac vein. Heart Rhythm 2006;3(4):464-6.

5. Kaseno K, Tada H, Tanaka S, Goto K, Yokokawa M, Hiramatsu S, et al. Successful catheter ablation of left ventricular epicardial tachycardia originating from the great cardiac vein: a case report and review of the literature. Circ J 2007;71(12):1983-8.

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Baris Bugan, Turgay Celik, Hasan Kutsi Kabul, Erkan Yildirim, Atila Iyisoy. Idiopathic Sustained Epicardial Ventricular Tachycardia Originating from the Great Cardiac Vein. J Clin Anal Med. 2015;6(6):790-792

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Bilateral Traumatic Anterior Shoulder Dislocation

Kerem Bılsel, Safak Sayar, Hasan Huseyin Ceylan, Mehmet Erdıl, Mehmet Elmadag, Ibrahim Tuncay

Bezmi Alem Vakif University Orthopaedy and Traumatology Department, Istanbul, Turkey

DOI: 10.4328/JCAM.1122 Received: 31.05.2012 Accepted: 05.08.2012 Publihed Online: 06.08.2012

Corresponding Author: İsmail Kerem Bilsel, Bezmi Alem Vakif University, Orthopaedy and Traumatology Department, Istanbul, Turkey. E-Mail: kbilsel@gmail.com

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Aim: The aim of this case report is to discuss the evaluation of potential complica-tions and treatment options associated with bilateral anterior shoulder disloca-tion. Material and Method: The data for this rarely encountered case was collect-ed, during the consultation and treatment phases for a 66-year-old female patient who first presented at the emergency department of Bezmiaiem Vakif University Medical Center with restriction of movements in her both shoulders after falling down the stairs in her home. Results: Evaluation of the patient’s pre-operative X-rays and computed tomography (CT scan) images and post operative evalua-tion of the shoulders was achieved using DASH and the Constant shoulder score.Discussion: Osteoporotic elderly patients and their relatives should be informed of possible complications when considering closed reduction of severe glenoid and humeral head fractures. Instead, an associated risk will most likely necessitate open reduction in this patient population after anesthesia has been administered for closed reduction. Hence, obtaining consent and educating the patient about a possibile need for internal fixation and prosthetic joint replacement using surgical implants should be included in the preoperative consultation and treatment plan-ning session before the patient receives sedation.

Keywords: Bilateral Shoulder Dislocation; Shoulder Arthroplasty

Full Text

Introduction

Although anterior shoulder dislocation is the most common major joint dislocation encountered in the emergency department, bilateral glenohumeral dislocations are rare and almost posterior. However, simultaneous bilateral anterior shoulder dislocation is even more rare, only about 30 cases were described in the literature [2] and bilateral anterior shoulder dislocations were reported at eight cases [3]. This report discusses a case involving a 66-years-old woman who sustained traumatic bilateral anterior shoulder dislocation as a result of falling down the stairs in her home. Patient confidentiality was protected and informed consent to describe her case was obtained in accordance with the Declaration of Helsinki and Good Clinical Practices and with approval of the local Ethics Committee of Bezmialem Vakif University Medical Center.

Case Report

A 66-years-old woman was admitted to emergency deparmtent with pain and restriction of movement on both sides of her shoulder. İnjury was occured simply falling at home, leaning forward with abducted both of her arm. Phisycal examination revealed squared of shoulders without any evidence of neurovascular deficit. Bilateral shoulder dislocation of this patient was proven with X-ray graphy (Figure 1). Right shoulder dislocation was closed reducted. After then while the closed reduction of the left side, iatrogenic humeral surgical neck fracture occured (Figure 2) and after a computerized tomography the humeral head was seen stucked in the anterior side of axilla (Figure 3). And surgical treatment was planned with endication of hemiartroplasty. The partial shoulder prosthesis (Figure 4) was applied with standart deltopectoral incision. Postoperatively early period pendulum and isometric exercises started and the velpau bandage was provided for the patient. At two-months follow-up, right shoulder abduction was 90 degree, anterior flexion was 110 degree; while left shoulder abduction and anterior flexion was 80 degree. İn order the disabilities of the arm, shoulder and hand (DASH) Score and constant shoulder score of the right and left shoulder was 46,7 and 57; 55,8 and 53.

Discussion

Shoulder dislocations are the most common major joint dislocations encountered in the emergency departments. They were reported to be 96 % anterior, 3 % posterior and 1 % inferior. However, simultaneus bilateral anterior shoulder dislocation is rare: only about 30 cases have been described in the literature [2] and bilateral anterior shoulder dislocations were reported at eight cases [3]. Bilateral shoulder dislocation was first described in 1902 in a patient with muscular contraciton caused by camphor overdose. Bilateral shoulder dislocation mechanism is forced extension, abduciton, and external rotation. Brown [4] reported the etiology of bilateral shoulder dislocations as 41 % acute spasm, 23 % trauma, and 36 % non-traumatic injuries. Bilateral shoulder dislocations are rare and almost always posterior [2] and seen usually after trauma, diabetic nocturnal hypoglicemia, grand-mal seizures, sports injuries or electric shocks. Three clinical factors are significantly associated with occurence of fractures in such dislocations: age 40 years or older, the first episode of dislocation, and mechanism of injury. Age is associated with decreased bone mass. The first episode of dislocation signifies an intact ligamentous anatomy around the shoulder joint. Mechanism of injury, such as a fall from height or a motor vehicle accident, are associated with high-energy trauma. After the shoulder joint dislocations; fractures, brachial plexus and axillary nerve injury,vascular and soft tissue damage and recurrent dislocation of the shoulder joint complications are seen. Bilateral shoulder dislocation in elderly patients with radiological examinations should be made and needed a good addition to the tomographic imaging techniques, such as the possible presence of a fissure line, and tubercle fractures also be considered. When attempting closed reduction, keep in mind that severely osteoporotic elderly patients may develop humeral head fractures and the patients and their relatives should be informed of possible complications. While under anesthesia, trying closed reduction; open reduction in these patients should be considered likely to be made. Hence the possibility of a possible fracture; surgical implants for internal fixation and prosthetic replacement have prepared in view is more correct to enter.

Competing interests

The authors declare that they have no competing interests.

References

1. Sharma L, Pankaj A, Kumar V, Malhotra R, Bhan S. Bilateral anterior dislocation of the shoulders with proximal humeral fractures: a case report.

J Orthop Surg 2005; 13:303-6.

2. Dunlop CC. Bilateral anterior shoulder dislocation: a case report and review of the literature. Acta Orthop Belg. 2002;68:168–170.

3. Segal D, Yablon IG, Lynch JJ, Jones RP. Acute bilateral anterior dislocation of the shoulders. Clin Orthop Relat Res 1979;(140):21-2.

4. Brown RJ. Bilateral dislocation of the shoulders. Injury 1984;15:267-73.

5. Emond M, Le Sage N, Lavoie A, Rochette L. Clinical factors predicting fractures associated with an anterior shoulder dislocation. Acad Emerg Med 2004;11:853–8.

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Kerem Bilsel, Safak Sayar, Hasan Huseyin Ceylan, Mehmet Erdil, Mehmet Elmadağ. Bilateral Traumatic Anterior Shoulder Dislocation. J Clin Anal Med. 2015;6(6):787-789

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Sinus Histiocytosis with Septic Embolism and Infective Endocarditis

Elif Torun Parmaksız 1, Ergün Parmaksız 2

1 Dr Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Göğüs Hastalıkları Kliniği, 2 Başkent Üniversitesi İstanbul Hastanesi, Nefroloji Kliniği, Türkiye

DOI: 10.4328/JCAM.1128 Received: 10.06.2012 Accepted: 05.08.2012 Publihed Online: 06.08.2012

Corresponding Author: Elif Torun Parmaksız, Dr. Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi, Göğüs Hastalıkları Kliniği, Cevizli, İstanbul, Türkiye. T.: +905062425356 E-Mail: dreliftorun@yahoo.com

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Rosai and Dorfman were the first to describe benign histiocytosis, also known as Rosai Dorfman disease. Since then, several case reports have been reported. This entity is a rare cause of lymphadenopathy. The clinical, laboratory, and biopsy findings of a sinus histiocytosis case is discussed and compared with previously reported cases. The distinguishing features of this case are isolated involvement of the axillary lymph nodes, accompanying chronic renal failure, infective endocar-ditis and septic embolism besides the rarity of the diagnosis of sinus histiocytosis.

Keywords: Sinus Histiocytosis; Rosai Dorfman Disease; Septic Embolism; Infective Endocarditis

Full Text

Introduction

Rosai and Dorfman described a clinicopathological entity called “sinus histiocytosis with massive lymphadenopathy”, better known as Rosai-Dorfman disease in 1969 (1). The first four cases reported were all children, with a disease characterized by massive lymphadenopathy, fever, hypergamaglobulinemia, increased erythrocyte sedimentation rate and leucocytosis [1-3]. Mediastinal, axillary and inguinal lymph nodes can also be affected and extranodal sites are involved in about 25% to 40% of cases [3].

The benign and self-limited course of the disease distinguishes it from malignant reticuloendotheliosis [2]. No specific treatment is required [4].

In this report we describe a case of sinus histiocytosis accompanied by infective endocarditis and septic embolism; to our knowledge, this is the first such case reported in literature.

Case Report

A 66 year-old female patient presented with a history of relapsing fever for 2 months. There had been mild cough and slightly disturbing chest pain. She had a history of chronic renal failure for 7 years and was on routine hemodialysis 3 times weekly. She was found to have severe anemia and had been receiving transfusions for 5 months. Her past history revealed a gastrointestinal system malignancy and chemotherapy 30 years ago. She had no other comorbidities. She had been thoroughly evaluated for anemia to rule a malignancy by Nephrology department in previous month. The abdominal computed tomography(CT), gastroscopy and colonoscopy remained nondiagnostic. The thoracic CT was found to be normal except for nonspecific millimetric parenchymal nodules. Bone marrow biopsy demonstrated hypercellular bone marrow. According to transthoracic echocardiography ejection fraction(EF) was 58% and there was mild mitral regurgitation and tricuspid regurgitation. The patient had a history of betalactam group antibiotic use. On admission, thoracic CT demonstrated diffuse, multiple, bilateral pulmonary parenchymal nodules of various sizes (Figure 1). The radiological differential diagnosis included infection or metastatic malignancy. Bronchoscopically no endobronchial lesion was detected, bronchial washings were negative for bacteria, fungi, acid-fast bacilli or atypical cells. She had a painless palpable lymph node of 1 cm on left axillary region. The excisional biopsy of the lypmh node revealed dilated sinuses filled with histiocytes with abundant pale eosinophilic cytoplasm. The histopathological diagnosis diagnosis was sinus histiocytosis with focal lymphoid proliferation ( Figure 2 ).

Meanwhile the clinical condition worsened by high fever, fatigue, arthralgia, nausea and vomiting . Laboratory findings were as follows: hemoglobin:7.77g/dl, hemotocrit:22.1 %, mean corpuscular volume:88.6 fL, leucocytes:8830/ul, plataelets:181000/ul, C-reactive protein:313 mg/l, eritrocyte sedimentation rate:124/hour, blood urea nitrogen:42 mg/dl, creatinine:4.81 mg/dl, sodium:134 mmol/l, potassium:4 mmol/l, albumin:2.8 g/dl, other biochemical tests were within normal limits. Connective tissue markers, c-ANCA and p-ANCA were negative. Another thoracic CT was taken and pulmonary nodules were found to increase in size and number, with cavities in some of them (Figure 3). Bronchoscopy was repeated and culture of the bronchial washings revealed methicillin sensitive Staphylococcus aureus. As clinical, radiological and microbiological findings pointed out septic embolism, echocardiography was repeated. Transthoracic echocardiograhy was suspectful for a 1,6×1 cm vegetation on atrial side of the tricuspid valve attached to the septal leaflet. Transesophageal echocardiography demonstrated 3 vegetations; first one 2×0.9 cm, mobile, on the catheter, extending into the superior vena cava; second 3×0.8 cm, mobile, originating from the tricuspid valve annulus; and third 0.8 cm, mobile, on right atrial lateral wall.

The patient was put on appropriate antibiotics with diagnosis of infective endocarditis and septic embolism, followed by surgery. All the clinical picture resolved and the patient was free of symptoms.

Administration of antibiotics prior to the exact diagnosis seem to mask the severe clinical picture of septic embolism and prevent bacterial growth on cultures. Due to their location, the vegetations could not be visualized by transthoracic echocardiography and the diagnosis remained obscure. The evaluation of fever of unknown origin requires careful and close follow-up accompanied by semi-invasive or invasive investigations, especially in patients with risk factors such as indwelling catheters.

Discussion

Sinus histiocytosis is a diffuse, lymphoproliferative disorder, mostly effecting children or young adults, although patients in elder ages have also been described [3]. Our case seems to be among the oldest cases described.

The disease has no known gender, ethnic or socieconomic predilection [5] . The etiology is generally unknown, although some cases have been linked to Ebstein Barr virus, cytomegalovirus, Brucella, Klebsiella or human herpes virus 6 [4-6]. Associated symptoms and signs may differentiate according to the size, site and number of lymph nodes involved or may be constitutional, such as fever and weight loss [3,4]. The affected extranodal sites may include skin and soft tissues, upper respiratory tract, orbit, testicle, kidney, thyroid, small bowel, breast, and bone [7].

Although early descriptions concluded that nearly every case was marked exclusively by cervical lymph node involvement, other organ systems may be affected. More than 90% of cases with sinus histiocytosis have cervical lymphadenopathy [8]. Axillary lymph nodes are not commonly involved in sinus histiocytosis. In evaluation of 2250 axillary lymph nodes removed from 487 autopsies, Tsakraklides et al found the incidence of sinus histiocytosis as 1.7% [9]. Another distinguishing feature of our case is involvement of axillary lymph nodes without cervical lymph node invasion.

Based on the fact that the laboratory findings include anemia, leukocytosis and increased ESR [3] , findings of our patient were consistent with literature.

In literature, cases of pleural effusion, mediastinal lymph node calcification, airway disease, cystic and interstitial lung disease [5,10] have been reported, however no association between infective endocarditis or septic pulmonary embolism has been described. As the severity of clinical picture was hidden by previous antibiotic use, the diagnosis of sinus histiocytosis was reached even before the underlying disease.

Considering the benign and self-limiting course of the disease, treatment is not required in most cases. Treatment is generally reserved for life-threatening complications or disfiguring enlarged lymph nodes. Corticosteroids [10] , chemotherapeutic agents such as etoposide, methotrexate, 6-mercaptopurine [11] , cyclophosphamide, rituximab [12], either alone or in combination, are among therapeutic agents used so far in treatment of Rosai Dorfman disease. Surgical excision and radiotherapy have also been tried [4] .

Some case reports in our country reveal a case with axillary, scalene and hilar lymphadenopathy [13] and another case with mediastinal and hilar lymph nodes [14] .

In conclusion, key distinguishing features of this case are isolated involvement of the axillary lymph nodes, accompanying chronic renal failure infective endocarditis and septic embolism besides the rarity of the diagnosis of sinus histiocytosis. This disease should be kept in mind in differential diagnosis of enlarged lymph nodes when no other predisposing disease coul be found.

Competing interests

The authors declare that they have no competing interests.

References

1. Rosai J, Dorfman RF. Sinus histiocytosis with massive lymphadenopathy: a newly recognized benign clinicopathological entity. Arch Pathol 1969;87:63-70.

2. Becroft DM, Dix MR, Gillman JC, Macgregor BJL,Shaw RL. Benign sinus histiocytosis with massive lymphadenopathy: transient immunological defects in a child with mediastinal involvement. J Clin Path 1973;26:463-9.

3. Abdollahi A, Ardalan FA, Ayati M. Extranodal Rosai-Dorfman disease of the kidney. Ann Saudi Med 2009;29(1):55–7.

4. Stones DK, Havenga C. Sinus histiocytosis with massive lymphadenopathy. Archives of Disease in Childhood 1992;67:521-3.

5. Ju J, Kwon YS, Jo KJ, Chae DR, Lim JH, Ban HJ, et al. Sinus Histiocytosis with Massive Lymphadenopathy: A Case Report with Pleural Effusion and Cervical Lymphadenopathy. J Korean Med Sci 2009;24:760-2.

6. Harley EH. Sinus histiocytosis with Massive lymphadenopathy (rosai dorfman disease) in a patient with elevated Epstein-barr virus titers. J NatI Med Assoc 1991;83:922-4.

7. Tiju JW, Hsiao CH, Tsai TF. Cutaneous Rosai-Dorfman disease: remission with thalidomide treatment. Br J Dermatol 2003;148:1060-1.

8. Jani PA, Banjan D. A case of Sinus Histiocytosis with Massive Lymphadenopa¬thy (Rosai-Dorfman Syndrome) from Western India . Mcgill J Med 2008;11(2):156–9.

9. Tsakraklides V, Tsakraklides E, Good RA. An Autopsy Study of Human Axillary Lymph Node Histology. Am J Pathol 1975;78:7-22.

10. Cartin-Ceba R, Golbin JM, Yi ES, Prakash UB, Vassallo R. Intrathoracic manifes¬tations of Rosai Dorfman disease Respir Med 2010;104(9):1344-9.

11. Horneff G, Jurgens H, Hort W, Karitzky D, Gobel U. Sinus histiocytosis with mas¬sive lymphadenopathy (Rosai-Dorfman disease): response to methotrexate and mercaptopurine. Med Pediatr Oncol 1996;27(3):187-92.

12. Petschner F, Walker UA, Schmitt GA, Uhl M, Peter HH. “Catastrophic systemic lupus erythematosus” with Rosai-Dorfman sinus histiocytosis. Succesful treatment with anti-CD 20/rutuximab. Dtsch Med Wochenschr 2001;126(37):998-1001.

13. Çırak K, Balıoğlu T, Karaca S, Kıraklı ÖK, Halilçolar H, Bayol Ü. Rosai Dorfman Hastalığı (Olgu sunumu) İzmir Göğüs Hastanesi Dergisi 2002;16(2):36-9.

14. Altıntaş N, Altınsoy B, Sarıaydın M. Rosai Dorman disease. J Clin Anal Med 2012;3(4):463-5.

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Elif Torun Parmaksiz, Ergun Parmaksiz. Sinus Histiocytosis with Septic Embolism and Infective Endocarditis. J Clin Anal Med. 2015;6(6):784-786

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Acute Hepatitis Associated with The Use of Herbal Tea (Fennel and Cumin)

Suat Zengin 1, Mehmet Murat Oktay 1, Murat Kamalak 1, Behcet Al 1, Cuma Yildirim 1, Hasan Büyükaslan 2

1 Emergency Department of Medicine Faculty of Gaziantep University, Gaziantep, 2 Emergency Department of Middle East Medical Center, Şanlıurfa, Turkey

DOI: 10.4328/JCAM.1190 Received: 03.07.2012 Accepted: 05.08.2012 Publihed Online: 06.08.2012

Corresponding Author: Suat Zengin, Emergency Department of Medicine Faculty, Gaziantep University, Gaziantep, Turkey. T.: +90 3423606060/77122 GSM: +905336408361 F.: +90 3423602244 E-Mail: zengins76@gmail.com

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Herbal remedies have become increasingly popular throughout the globe as a result of disappointment with conventional medicines. The public often regards them as harmless. However, some of these products or their metabolites can cause adverse effects such as liver damage. In this study, two patients who devel-oped acute hepatitis due to consuming herbal tea are presented. Twenty-six and thirty-year-old two women were admitted to our department with symptoms of nausea, vomiting, anorexia and weakness. Serum alanine aminotransferase and aspartate aminotransferase levels were increased; all serological tests for viral hepatitis and autoimmune disorders were negative. They had consumed an herbal tea containing fennel and cumin to increase lactation everyday for three-four weeks. Discontinuation of the herbal tea resulted in normalization of liver en-zymes four-five weeks later. To the best of our knowledge, this is the first report of hepatitis possibly related to use of an herbal tea containing fennel and cumin. This study suggests that herbal tea containing fennel and cumin can cause hepa-totoxicity, which could be clinically confused with other causes of acute hepatitis. Clinicians may face with a case of acute hepatitis that is not readily diagnosed, and should question patients about herbal remedy use.

Keywords: Hepatotoxicity; Herbal Remedy; Fennel; Cumin

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Introduction

Herbal remedies are widely and routinely used worldwide. As they are generally commercially available without medical prescription and are known as ‘natural products’, they are generally believed to be harmless. Hepatitis due to herbal remedies has previously been infrequently reported. However, recently hepatitis associated with herbal remedies has been increasingly reported in literature and new agents have been continuously added to the list [1-3]. Nevertheless, pathogenic mechanisms are not well defined and the true incidence is probably underestimated. Cumin (Cuminum Cyminum) has been used for treatment of toothache, dyspepsia, diarrhea, epilepsy and jaundice [4]. Fennel (Foeniculum Vulgare) and its herbal drug preparations have been used for treatment of many gastrointestinal and respiratory disorders [5]. This case report describes two breast-feeding women that developed acute hepatitis due to drinking an herbal tea containing fennel and cumin. This is the first report of hepatitis related to use of a mixture containing both cumin and fennel.

Case Report 1

A 26-year-old woman was admitted to our department with symptoms of nausea, vomiting, anorexia, weakness and abdominal discomfort. The physical examination was unremarkable. Her medical history was negative for hepatic and metabolic disorders (such as obesity, diabetes mellitus, atopy). She denied alcohol or hepatotoxic orally or intravenously drug abuse (e.g. nonsteroidal anti-inflammatory drugs), recent foreign travels, sexual risk factors and blood product transfusions. She said that she delivered 40 days ago. The patient also mentioned that for the past 30 days she consumed daily 2-3 cups of herbal tea containing fennel and cumin to increase lactation and relieve abdominal discomfort.

The initial laboratory values revealed: serum aspartate aminotransferase (AST) 467 IU/l (reference range [RR] 5–34 IU/l), alanine aminotransferase (ALT) 608 IU/l (RR 3–55 IU/l), ɣ-glutamyl transferase (GGT) 160 IU/l (RR 9–36 IU/l), alkaline phosphatase (ALP) 478 IU/l (RR 40–150 IU/l), total bilirubin 2.29 mg/dl (RR 0.2–1.2 mg/dl) and conjugated bilirubin 0.85 mg/dl (RR 0.0–0.5 mg/dl). Coagulation studies and other laboratory tests, including a complete blood count, serum urea nitrogen, creatinine, glucose, electrolytes, total protein and albumin were normal. Results of serological tests for viral hepatitis A, B and C, Cytomegalovirus, Epstein-Barr virus, types 1 and 2 herpes simplex viruses were negative, as well as serological tests for autoimmune disorders. Moreover, serum ceruloplasmin and α1-antitrypsin were normal. Abdominal ultrasonography showed mild hepatic steatosis and a normal biliary tract.

The herbal tea was stopped after admission and the patient was treated conservatively. Frequent assessment of the liver function was performed. The patient recovered clinically over the next five weeks. The patient’s liver function tests returned to normal five weeks later.

Case Report 2

A 30-year-old woman was admitted to our department with symptoms of nausea, vomiting, anorexia and weakness. The physical examination was unremarkable. Her medical history was negative for hepatic and metabolic disorders (such as obesity, diabetes mellitus, atopy). She denied alcohol or hepatotoxic orally or intravenously drug abuse (e.g. nonsteroidal anti-inflammatory drugs), recent foreign travels, sexual risk factors and blood product transfusions. She said that she delivered 25 days ago. The patient also mentioned that during the past 20 days she consumed daily 1-2 cups of herbal tea containing fennel and cumin to increase lactation.

On admission, the laboratory results were: AST 337 UI/l (RR 5–34 UI/l), ALT 445 UI/l (RR 3–55 UI/l), GGT 349 UI/l (RR 9–36 UI/l), ALP 264 UI/l (RR 40–150 UI/l), total bilirubin 0.45 mg/dl (RR 0.2– 1.2 mg/dl) and conjugated bilirubin 0.22 mg/dl (RR 0.0–0.5 mg/dl). Coagulation studies and other laboratory tests, including a complete blood count, serum urea nitrogen, creatinine, glucose, electrolytes, total protein and albumin were normal. Results of serological tests for viral hepatitis A, B and C, Cytomegalovirus, Epstein-Barr virus, types 1 and 2 herpes simplex viruses were negative, as well as serological tests for autoimmune disorders. Moreover, serum ceruloplasmin and α1-antitrypsin were normal. Abdominal ultrasound and a computed tomography scan of the abdomen were both normal.

The herbal tea was discontinued upon admission and the patient was treated conservatively. Frequent assessment of the liver function was performed. Her liver function tests progressively decreased and returned to normal after four weeks and the patient completely recovered.

Discussion

Herbal remedies have been used worldwide to treat many different diseases for thousands of years [1-3]. Recently, herbal remedies have been widely advertised as harmless medication for a variety of ailments. Many patients consider herbal remedies as natural and harmless medications, and are turning toward the internet for information regarding their illness and are discovering the potential uses of herbal preparations. However, recently reported cases of hepatitis induced by herbal remedies [1-3] indicate that herbal remedies may not be entirely safe.

The liver is a key organ of metabolism, secretion and extraction. As for herbal remedies, the toxic ingredients and mechanisms of liver injury are not clearly known because of the complexity of herbal remedies and partial knowledge of their action mechanism. However, direct hepatotoxic effect, hypersensitivity and idiosyncratic reactions have been proposed [6;7]. It is often difficult to identify the exact toxic component of herbal remedies, since they contain multiple ingredients, individual components may not be pure substances and not all components may be listed.

The true incidence of herbal remedy induced hepatitis remains unknown because the diagnosis of toxicity induced by an herbal remedy is difficult since there are no specific tests or diagnostic criteria. Careful history taking, laboratory findings, and histopathology are used to diagnose toxicity induced by herbal remedies [5-7]. Careful history taking is crucial in order to obtain the correct diagnosis. However, such information is not always available. It has been shown that most patients who take herbs do not inform their physicians. Moreover, most physicians do not ask patients whether they have taken herbal remedies [7].

Fennel (in Turkish “Rezene”) and cumin (in Turkish “Kimyon”) are natively found in the north and west regions of Turkey. They are cultivated for the herb as a spice (flavouring salads) and medicine in Turkey. Herbal tea containing fennel and cumin is consumed by women to increase lactation during the postpartum period. Until now there has been no documented case of hepatotoxicity due to herbal tea containing fennel and cumin. Although the mechanism of toxicity remains elusive, we think that it is probably due to idiosyncratic reactions or direct hepatotoxic effect. In the above mentioned cases, the diagnosis of hepatitis associated with herbal tea administration was based on a review of the patient’s history, clinical findings, laboratory abnormalities, exclusion of other causes of acute hepatocellular necrosis, the time association between the administration of the herbal tea and onset of symptoms and the fact that, after discontinuation of the herb, the patient improved and progressively recovered completely [1-3;5;6].

Herbal remedy induced liver injury is a new found problem. The use of herbal remedies must be considered a possible etiology in the setting of clinical and/or biochemical manifestations of liver injury, especially now that alternative medicine and herbal treatments have growing appeal in many societies. The above-described cases suggest that herbal tea containing fennel and cumin may be a cause of hepatitis, clinically indistinguishable from hepatitis of other etiologies. Thus, it highlights the fact that some herbal remedies may not be as safe as they are widely considered. Physicians and health officials need to warn the public of the potential danger of herbal remedies and to consider herbal remedies in the differential diagnosis of unexplained hepatitis.

Competing interests

The authors declare that they have no competing interests.

References

1. Cardenas A, Restrepo JC, Sierra F, Correa G. Acute hepatitis due to shen-min: a herbal product derived from Polygonum multiflorum. J Clin Gastroenterol 2006;40(7):629-32.

2. Yang HN, Kim DJ, Kim YM, Kim BH, Sohn KM, Choi MJ et al. Aloe-induced toxic hepatitis . J Korean Med Sci 2010;25(3):492-5.

3. Starakis I, Siagris D, Leonidou L, Mazokopakis E, Tsamandas A, Karatza C. Hepatitis caused by the herbal remedy Teucrium polium L. Eur J Gastroenterol Hepatol 2006;18(6):681-3.

4. Nostro A, Cellini L, Di Bartolomeo S, Di Campli E, Grande R, Cannatelli MA et al. Antibacterial effect of plant extracts against Helicobacter pylori. Phytother Res 2005;19(3):198-202.

5. Ozbek H, Uğraş S, Dülger H, Bayram I, Tuncer I, Oztürk G et al. Hepatoprotective effect of Foeniculum vulgare essential oil. Fitoterapia 2003;74(3):317-9.

6. Woolf GM, Petrovic LM, Rojter SE, Wainwright S, Villamil FG, Katkow WN, et al. Acute hepatits associated with the Chinese herbal product Jin Bu Huan. Ann Intern Med 1994;15(10):729–35.

7. Chitturi S, Farrell GC. Herbal hepatotoxicity: an expanding but poorly defined problem. J of Gatroenterol and Hepatol 2000;15(10):1093–9.

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Suat Zengin, Mehmet Murat Oktay, Murat Kamalak, Behcet Al, Cuma Yildirim, Hasan Buyukaslan. Acute Hepatitis Associated with The Use of Herbal Tea (Fennel and Cumin). J Clin Anal Med. 2015;6(6):781-783

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Percutaneous Cystolithotripsy in Pediatric Bladder Stone: Case Report

Bayram Guner

Mus State Hospital, Department of Urology, Mus, Turkey

DOI: 10.4328/JCAM.1196 Received: 12.07.2012 Accepted: 05.08.2012 Publihed Online: 06.08.2012

Corresponding Author: Bayram Guner, Mus State Hospital, Department of Urology, 49000, Mus, Turkey. T.: +905325829016 F.: +90 2165709165 E-Mail: gunerbayram@yahoo.com

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Pediatric urolithiasis cases are observed 1-5% in developed countries. We aim at sharing our percutaneous cystolithotripsy experiment which is scarcely applied on this case group observed rarely in childhood. We think that percutaneous cys-tolithotripsy is an alternative treatment which is effective, reliable and provides minimal morbidity and also has a high success rate in childhood bladder stones as in adults.

Keywords: Bladder; Calculi; Percutaneous; Cystolithotripsy

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Bayram Guner. Percutaneous Cystolithotripsy in Pediatric Bladder Stone: Case Report. J Clin Anal Med. 2015;6(6):778-780

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A Rare Heart Rhythm Problem in Acute Rheumatic Fever: Complete Atrioventricular Block

Ayse Esin Kibar 1, Sevcan Erdem 1, Mehmet Burhan Oflaz 2

1 Departments of Pediatric Cardiology, Mersin Women’s and Children’s Hospital, Mersin, 2 Departments of Pediatric Cardiology, Cumhuriyet University School of Medicine, Sivas, Turkey

DOI: 10.4328/JCAM.1185 Received: 29.06.2012 Accepted: 30.07.2012 Publihed Online: 30.07.2012

Corresponding Author: Kibar Ayse Esin, Mersin Women’s and Children’s Hospital, Mersin, Turkey. T.:+90 3242230701 E-Mail: dreseresin@yahoo.com

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Rheumatic heart disease remains the most important cause of acquired heart disease in children and young adults. Different kinds of rhythm and conduction disturbances may be seen during the course of acute rheumatic fever (ARF). Long PR intervals are found commonly in rheumatic fever, but complete atrioventricu-lar (AV) block is an exceptionally rare manifestation. This case report is about a 14 year-old-female patient diagnosed as ARF based on migratory arthralgia and mild carditis who also developed complete heart block on admission. Electrocar-diogram on the 3rd day of hospitalization depicts 2nd degree atrioventricular block (Mobitz I) combined with PR prolongation. The ECG revealed a normal sinus rhythm with PR prolongation on the 4th day of hospitalization. Rarely, complete AV heart block can occur as a complication of ARF and may develop during the acute phase.

Keywords: Rheumatic Fever; Carditis; Atrioventricular Block; Rhythm

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Ayse Esin Kibar, Sevcan Erdem, Mehmet Burhan Oflaz. A Rare Heart Rhythm Problem in Acute Rheumatic Fever: Complete Atrioventricular Block. J Clin Anal Med. 2015;6(6):775-777

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Review Article

Contemporary Management of Acute Biliary Pancreatitis

OrhanVeli Özkan 1, Orhan Yağmurkaya 2, Erhan Şit 2

1 Department of General Surgery, Faculty of Medicine, 2 Department of General Surgery, Research and Educational Hospital, Sakarya University, Sakarya, Türkiye

DOI: 10.4328/JCAM.2207 Received: 09.12.2013 Accepted: 13.01.2014 Published Online: 14.01.2014

Corresponding Author: Orhan Veli Ozkan, Sakarya University, Faculty of Medicine, Department of General Surgery, Sakarya, Turkey. GSM: +905323417440 F.: +90 2642552105 E-Mail: veliorhan@hotmail.com

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Acute biliary pancreatitis is one of the major causes of acute pancreatitis.Gallstones, biliary sludge and microlithiasis, especially in pancreatitis without detectable reason, can be the cause of acute pancreatitis. Acute biliary pan-creatitis has many controversions in the literature, and its classification and guidelines are being updated very frequently. Atlanta classifications which determine the definitions and guidelines about acute pancreatitis were re-newed and published in 2013. It has various clinical aspects, ranging from a mild form which is easily treated, to a severe form that causes complications leading to mortality. The pathogenesis of this disease has not been fully elucidated and several theories have been suggested. New scoring systems and laboratory methods such as proteomics have been suggested for both diagnosis and to predict disease severity, and research on these topics is still in progress. Novel therapeutic approaches with technological developments such as ERCP, ES, MRCP, and EUS are also suggested.

Keywords: Acute Biliary Pancreatitis; Diagnosis; Predictors Severity; Treatment

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Introduction

Acute pancreatitis is the reversible paranchymal injury related to the pancreatic inflammation, which can be observed in local and distant extrapancreatic tissues[1].Gallstones are among the major causes.Small gallstones and sludge are the most frequent acute pancreatitis causes in the Western world[2,3]. If any etiological factor cannot be detected, the disease is referred to as idiopathic acute pancreatitis. However, some of these cases can be related to microlithiasis[4].

Acute pancreatitis caused by gallstones was defined in 1901 by Eugene Opie with the common canal theory.Gallstones fall to the duodenum in 70% of the cases[5,6].However, this situation may differ with the severity of acute pancreatitis, duration of the temporary obstruction in the middle canal or its persistance.

In this review, diagnosis, prediction criteria for pancreatitis severity, scoring systems and treatment approaches for acute biliary pancreatitis(ABP), which is among the most frequently observed acute pancreatitis.

Diagnosis

The diagnosis of acute pancreatitis is made if at least two of the following three criteria are met: 1-Acute abdominal pain 2- Elevated pancreatic enzyme levels in blood, urine or acidic liquid 3- Abnormal imaging findings in pancreas that are related with acute pancreatitis.If the diagnosis is made on this basis, other pancreatic diseases and acute abdomen reasons can be ruled out[7].Distinguishing between acut biliary pancreatitis and other causes of acute pancreatitis is important for disease management and prognosis.

Symptoms and signs

Various clinical symptoms and signs, including abdominal pain, nausea, vomiting, ileus, subileus, reduced bowel sound, fever, jaundice, pain extending to the dorsum, shock, anorexia, abdominal muscular rigidity and neurological symptoms can be observed in acute pancreatitis.

Acute pancreatitis sometimes cause color change in the skin in side abdominal wall(Grey Turner’s sign), around the belly(Cullen’s sign), or on the lower part of inguinal ligament(Fox’s sign)[7].

Abdominal pain is observed in approximately 95% of the cases.In patients with biliary pancreatitis, pain is localized more on the right upper quadrant[8,9].The presence of gallstones in patient history helps to consider ABP in the diagnosis. Vomiting is associated with peripancreatic inflammation extending to the posterior gastric wall and local/generalized ileus[9].

Other frequent symptoms and signs in patients with acute pancreatitis includepain extending to the dorsum, loss of appetite, jaundice, muscular defence, meteroism and hematemesis[10].

Current diagnostic biomarkers

Serum amilase and lipase levels are standard blood tests. Serum amilase levels increase rapidly in the onset ofacute pancreatitis (3-6 hours), persist for 3-5 days[11].Moreover, amilase levels may increase due to other reasons except acute pancreatitis, such as perforated peptic ulcer, perforated/obstructed bowel, mesenteric infarction, trauma, salivary diseases, cholecystitis andperitonitis[12]. Lipase values are more sensitive compared to amilase. In addition to these, hyperglysemia, hypocalcemia, leukocytosis, anemia, moderate hyperbilirubinemia and an increase in liver enzyme levels can be observed.

In 2007, American Academy of Family Physicians emphasized to use amilsae and lipase values, whole blood count, blood urea, creatinine, glucose, calcium, triglyceride, urine examination and arterial blood gas in the diagnosis and treatment of acute pancreatitis. Additional research biomarkers may include trypsinogen activation peptide(TAP), CRP, procalcitonin, phospholipase A2 and the cytokines interleukin-6 and interleukin-8[13].

While several prognostic biomarkers, including procalcitonin, serum interleukin-6, interleukin-8, polymorphonuclear elastase and serum CRP, have been investigated, the research on diagnostic test had less efficiency[14,15].Certain interesting biomarkers have been defined; yet, when compared with lipase, their lower accuracy and requirement for slow techniques which are not suitable for clinical laboratories and fastdiagnosis prevented their widespread use.PhospholipaseA2, pancreatic elastase, urinetrypsinogen activated protein(TAP), carboxypeptidaseB(CAPB), activation peptide of carboxypeptidase B(CAPAP), trypsin-2-alpha1 antitrypsin complex(trypsin-2-AAT) and circulating(cell-free) DNA are examples for such laboratory biomarkers which did not find widespread use[12].

As a novel approach, “proteomics” studies have increasing importance and these studies accelarated following the completion of the human genome project, and found a widespread area of application. Despite the fact that genomics has been the dominant research area in biomedical studies in recent years, research on proteomics is rapidly spreading among scientific research groups and clinical research laboratories[16].Currently, there are ongoing proteomic studies on acute pancreatitis, and they are expected to have key positions to determine both diagnosis and prognosis. There are ongoing proteomics studies on novel potential biomarkers, including protein disulfide isomerase related protein, dnaK-type molecular chaperone hsp72-ps1, mitochondrial glutamate dehydrogenase, similar to chaperonin containing TCP-1β subunit, RuvB-like protein1, heterogeneous nuclear ribonucleoprotein H1, aldehyde reductase1, triosephosphate isomerase1, peroxiredoxin2, heat shock protein90, mitochondrial ATP synthaseβ chain precursor, tubulinβ chain, 3-mercaptopyruvate sulfurtransferase and mitochondrial ATP synthase subunit D[12].

Imaging finding of ABP

CT is the major imaging method to evaluate acute pancreatitis. It is important to detect the disease and to evaluate its severity.What is more important, probably, is that CT is considerably useful to evaluate situations presented with clinical symptoms similar to acute pancreatitis, such as duodenal ulcer perforation, ruptured aortic aneurism and mesenteric ischemia[17,18].

Ultrasonography(US)is a relatively sensitive method to evaluate gallbladder and biliary tracts, and its feasibility and mobility ensures point-of-care evaluation. However, the fact that the distal parts of the coledoc cannot be evaluated due to bowel gas superposition constitutes a disadvantage of this method. Stones causing acute pancreatitis are generally smaller than 5mm[19].

Magnetic resonance imaging(MRI) is considerably successful to show biliary tracts and pancreatic ducts that contain stable fluid. These sequences can be used to perform magnetic resonance cholangiopancreatography(MRCP), and it is the non-invasive alternative to endoscopic retrograde cholangiopancreatography(ERCP). For common bile duct stones, MRCP’s sensitivity and specificity is above 90%[20].

Identification of acute biliary pancreatitis

The first recommendation in ABP definition is to inspect the presence of stones in the gallbladder and/or coledoc usingUS. The sensitivity of US to detect gallstones exceeds 95% in uncomplicated cases. However, in cases of acute pancreatitis, the sensitivity is only 67-78% due to ileus and bowel distention. Furthermore, the sensitivity ranges between 25-90% for detecting common bile duct stones.Detecting especially small stones that cause pancreatitis, even the probability of these stones passing to the intestine makes the detection of common bile duct stones using US complicated.

Alanine aminotransferase (ALT), elevated γ-glutamyltransferase

(GGT) and bilirubin also leads to a suspection of ABP, but it should be noted that ABP may be present although these parameters have normal levels. If gallstones are not detected by US, and presence of jaundice and elevated biochemical parameters indicate ABP. MRCP and endoluminal US(EUS), which have higher sensitivity and specificity, should be performed. MRCP has high sensitivity(84-95%) and specificity (96-100%) to detect common bile duct stones. EUS, similar to MRCP, has high degree to detect stones in the main biliary tracts[21,22].

Pathophyisiology

While only 3-7% of the patients who have gallstone in the gallbladder are known to develop pancreatitis, clearing residual gallstones by cholecystectomy or ERCP after pancreatitis prevents recurrent pancreatitis attacks. When left untreated, the recurrence rate of gallstone pancreatitis ranges between 32-61%[23].Sludge that causes stasis in biliary flow is among the causes of acute pancreatitis. Sludge consisting of cholesterol crystals and calcium granules may include stones smaller than 5mm. It forms a dense layer in the gallbladder. Behaving similarly to gallstones, it may cause acute pancreatitis and similarly, cleaning coledoc using cholecystectomy and ERCP may prevent recurrent pancreatitis attacks[24,25].

Experimental studies have demonstrated that biliary reflux was not a necessity for acute pancreatitis development, and pancreatitis may develop as a result of pancreatic duct obstruction[26].According to another theory, insufficient inhibition of intracellular trypsinogen activation leads to an increase in pressure in the pancreatic duct when exocrine pancreas is hyperstimulated, active trypsin reflux is elevated and thereby, pancreatic injury develops[27].

Biliary tract stones that cause pancreatitis may not be presented radiologically in all cases. The stone might have passed the Oddi sphincter or it could be really small, referred to as microlithiasis, which cannot be presented with conventional abdominal US[28].Microlithiasis condition may cause recurrent pancreatitis as the migration of the stones is easy. Moreover, hepatic transaminase levels are also normal in 15-20% of these cases[29].

In 1901, Eugene Opie proposed the “common channel theory”[5]. Main biliary tract and pancreatic duct open to the duodenum with a common canal, and a gallstone localized to ampulla Vater causes an obstruction at this location, leading to gallbladder reflux and pancreatitis[3]. Acosta andLedesma[30] suggested that biliary reflux associated with the temporary obstruction in papilla, which is caused by the migration of gallstones to the duodenum, might cause pancreatitis.In the end, biliary reflux due to obstruction or gallbladder itself can damage the protective barrier in the pancreatic cells, or activate pancreatic enzymes via indirect mechanisms to cause pancreatitis.

Duodenal reflux theory is defined as the damage exerted by gallstones on the muscular layer of oddi sphincter during their migration to the duodenum, and subsequent retrograde flow of the duodenal content into the pancreatic duct[31].According to another theory[1], the increase in pancreatic permeability in the pancreatic duct due to the obstruction that is caused by the stones, can lead to pancreatic enzymes to overcome the protective barrier to cause pancreatitis.

Inflammation is generally limited to a localized zone of injury.However, in certain cases, the severity of inflammation turns into systemic inflammatory response syndrome(SIRS) due the overactivation of the inflammatory cascade which is regulated by cytokines, immunocytes and the complement system. Inflammatory cytokines cause macrophages to migrate to distant organs, such as lungs or liver. Immunocytes stimulated by the cytokines released from macrophages secrete more cytokines, free radical and nitric oxide. Certain cytokines and proteins that play roles in disease progression, including IL-1, IL-6, IL-8, IL-10, TNF- α, monocyt chemoattractant protein, macrophage inhibitor factor, C-reactive protein and serum amyloid A, are important for monitoring the disease[1].

Prediction of Disease Severity

The severity of the disease is evaluated by combining clinical and laboratory findings, and using Atlanta criteria, Ranson criteria and acute physiology and chronic health evaluation II(APACHE II)scoring system. CT severity index developed by Balthazar et al. is used to evaluate the disease severity[32].In this index, necrosis and presence, amount and extension of fluid collections are evaluated and a patient is given a score.

Serum C-reactive protein(CRP)(cut–off >150)is suggested to evaluate the severity of acute pancreatitis 48-72 hours after its onset[12].

Scoring systems including multiple criteria have been defined 30 years ago to predict the disease prognosis and severity. Among these systems are Bank, Agarwal-Pitchumoni, Ranson, Glasgow (Imrie), APACHE II, BISAP, Balthazar, and Atlanta criteria.

In addition, Japanese clinical practice guidelines for acute pancreatitis was published in 2003 in Japan, and in 2006 in English. Later on,the Japanese Ministry of Health, Labour and Welfare developed novel diagnostic criteria in 2008 and revised the acute pancreatitis severity scoring system[33].

Ranson score

Ranson criteria, which is a pancreatitis-specific scoring system, is based on the evaluation of certain clinical and laboratory findings at the time of admission and at 48th hour. It consists of a total of 11 parameters, 5 of which are measured at the time of admission, and 6 of which are measured within the first 48 hours[33]. It is modified for ABP(Table)[34,35].Glasgow prognostic criteria including 8 parameters was defined by Imrie.

APACHE classification

APACHE criteria, which consisted of 34 criteria, was defined in 1981.However, due to its impractical use, it was modified as APACHE II, which included 12 criteria, in 1985.The sensitivity of this scoring system to determine pancreatitis severity is 75%, whereas it has a specifity of 92%[36,37].

APACHE III consisting of 18 criteria was defined in 1991, and with the addition of obesity, APACHE-O was defined in 1996.In a metaanalysis study on obesity(BMI>30), the incidence of systemic and local complications were higher[38].The incidence of mortality is below 4% in patients with an APACHE II score less than 8. The incidence of mortality ranges between 11-18% in patients who have APACHE II scores of 8 or more[39].

Global consensus and a practicable classification system for acute pancreatitis were offered in the Atlanta Symposium in 1992. This classification provided standardisation in study reporting and communication between clinicians was improved. In time, a revision had been mandatory since some deficiencies were noticed and knowledge about the disease was improved. Atlanta criteria were renewed in 2013.This revision is not intended to be a management guideline. [40].

According to the Atlanta criteria which were defined in 1992, the presence of one or more of the following indicates that acute pancreatitis will have a severe course[41]:1-A Ransonscore of 3 or high levels in the first 48 hours. 2-APACHE II score of 8 or higher at any given time.3-Single or multiple organ failure. 4-Single or multiple local complication(necrosis, pseudocyste, abcess).The main changes in the recent Atlanta criteria are:there are two phases of acute pancreatitis in the revised classification, early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis which is also the most common form is without any organ failure, local or systemic complications and usually resolves in a week. Presence of transient organ failure, local complications or exacerbation of co-morbid disease is the main considerations of moderately severe acute pancreatitis. Severe acute pancreatitis is described by persistent organ failure (more than 48 hours). Peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected) are the local complications. Standardised template for reporting CT images is also described[40].

BISAP;a scoring system consisting of five parameters stated below and which gained prospective value in the recent years[42]:BUN >25 mg/dl, altered mental status, SIRS, age>60, pleural effusion.

Balthazar classification

CT and especially dynamic contrast CT gives valuable information about disease severity and prognosis in acute pancreatitis. Balthazar classification which is based CT results was defined in 1985[32].This classification includes the degree of pancreatic enlargement and inflammation severity, presence and amount of fluid collection and the degree of pancreatic necrosis.

Bank and Agarwal criteria

Researchers like Bank and Agarwal have also identified prognostic systems consisting of different parameters and which are known with their names[44].

Treatment of Acute Biliary Pancreatitis

While most of the attacks in acute pancreatic inflammation are edematous/mild acute pancreatitis that regresses in 5-7 days, necrotizing/severe acute pancreatitis that may lead to mortality may develop in approximately 20% of the cases[45].Therefore, all patients with acute pancreatitis should be hospitalized and given initial supportive care, their disease etiologies should be evaluated and resolved, the severity of pancreatitis should be evaluated, and advanced treatment approach should be planned in accordance with the disease severity(Figure)[7,21,22].

Supportive care

In all cases with acute pancreatitis, the initial treatment should include discontinuing oral intake, intravenous fluid replacement and pain management[46].Mild pancreatitis attack rapidly regresses with this treatment, and with regressing abdominal pain, disappearance of nausea and vomiting and normal appetite, oral intake is started again. However, if oral intake does not seem to be possible within 5-7 days, nutritional support should also be added to the treatment[47].

Due to inflammation, there is a significant fluid loss to third spaces such as the interstitial space, and microcirculation is altered as a result of decreasing intravascular volume. This situation both facilitates the development pancreatic necrosis and leads to systemic complications through acute renal failure and the increase in intestinal bacterial translocation[48].Therefore, sufficient fluid and electrolyte replacement play a key role in protection from the systemic complications of acute pancreatitis. Early oxygen support to stabilize arterial oxygen saturation over 95% and fluid resuscitation has been reported to be associated with early regression and mortality in cases of organ failure[49].While the rate of fluid replacement with isotoniccrystalloids and colloids, when needed, has not been established with clinical studies, the general approach recommends a rate of 250-300cc/hour and a urination rate of 0.5-1.0cc/kg/hour is aimed[50,51].

Nasogastric application is not always necessary, but is suggested in case of bowel obstruction or severe nausea-vomiting. H2 receptor blockers and PPIs should be considered for acute mucosal lesions and gastrointestinal bleedings[45].

Discontinuing oral intake and nutritional treatment

Nutritional support is not necessary as inflammation will be rapidly over in most of the cases. However, if oral intake does not seem to be possible within 5-7 days, enteral nutrition should also be added to the treatment[47].This situation is frequently observed in patients with severe acute pancreatitis, and especially enteral nutrition started within the first 48 hours of hospitalization has been reported to significantly reduce mortality in severe acute pancreatitis[52].Medical nutrition is recently understood and has increasing importance in patients with acute pancreatitis. Contrary to previous knowledge, preferring enteral nutrition, rather than parenteral nutrition[18].Microorganisms infecting the necrotising pancreatitis generally originate from bowel, and are associated with increased bacterial translocation. Therefore, enteral nutrition is the main treatment approach to ensure the integrity of intestinal epithelia, thereby ensuring mucosal barrier integrity to decrease the translocation[53].

Pain management

Pain management is one of the steps in acute pancreatitis treatment.Especially morphine is known to increase oddi sphincter contraction and bupremorphineis recommended in Japanese guidelines, opioid agonist meperidin(petidin) is frequently used for this purpose. Nonsteriod antiinflammary drugs (NSAIDs), on the other hand, may be used additionaly for pain management in cases where narcotics have weak effect or alone in cases with mild symptoms. Albeit, the use of NSAIDs have been reported to reduce the frequency of post-ERCP pancreatitis in patients without oddi sphincter dysfunction, due to antiinflammtory effect[54].

Procedures targeting etiological factor

If cholangitis and extended passage disorder is suspected in patients with ABP, endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy (ERCP /ES) should be performed in the early stage. If ABP patients have gallstones, it is not recommended to treat bile duct stones with ERCP/ES. Laparoscopic cholecystectomy(LC) is suggested to be performed immediately following disease stabilization.Early cholecystectomy and ERCP reduce the recurrent ABP attacks[55].

LC prevents situations including recurrent ABP, cholesistitis, coledoc obstruction, cholangitis and biliary cholic. Regarding the timing of cholecystectomy, presence of complications such as severity of pancreatitis, local complications and organ failure, and their resolution is crucial. In the PONCHO study[56],early cholecystectomy performed in the first 72 hours was compared to cholecystectomy with a 25-30 day interval in patients with mild ABP. According to this study, the incidence of readmission and mortality were lower in patients who underwent early cholecystectomy.

Four approaches can be employed to investigate the ABP biliary tract and to treat the gallstones in the main biliary tract:A-ERCP/ES can be performed prior to the surgery; after the diagnosis and treatment of gallstones in the main biliary tract. LC should be performed. B-LC and intraoperative cholangiography(IOC), instead of ERCP, can be performed;if a gallstone is detected in the main biliary tract, the procedure can be converted to the open surgery and then coledoc exploration and gallstone treatment can be performed C- If a gallstone is detected in the main biliary tract using IOC, the procedure can be completed laparoscopically. ES should be performed either during the surgery or in the post-operative phase.D-If a gallstone is detected in the main biliary tract using IOC, coledoc exploration and gallstone treatment can be performed laparoscopically.

Antibiotic treatment and other treatments

Prophylactic antibiotic use is not suggested in cases of mild acute pancreatitis, its use in sterile necrotizing pancreatitis is controversial, because resistant bacterial or fungal infections may develop in prophylactic antibiotic use[57].On the other hand, the incidence of infected necrosis may reach to 40-70% in patients with necrotizing pancreatitis[58].As a result of the studies on this topic, 14-day ab initio antibiotic prophylaxis using broad-spectrum carbapenems, which have good penetration into the pancreas, is recommended in cases with pancreatic necrosis rates higher than 30%[18]. If infection is suspected in cases with fever or deterioration of general condition despite antibiotic prophylaxis or if these conditions are observed in the follow-ups, bacteriological examination should be performed using pancreatic thin needle aspirationand surgical debridement should not be delayed when needed[18,58].

In most studies, the use of gabexatemesilate in acute pancreatitis did not decrease the frequency of surgical intervention and mortality, but reduced the frequency of complications[59].In another study,a reduction in complication frequency and mortality rates has been reported after a 7-day infusion treatment with 2400mg/day dose of gabexatemesilate[60].Hence, the use of protease inhibitors in severe acute pancreatitis is currently controversial.

While the ability of somatostatin and its analog octreotide to suppress the exocrine secretions of the pancreas, and therefore rest the inflamed pancreatic tissue has caused therapeutic expectations, their efficiency was not demonstrated except for a single study[61,62].Somatostatin and octreotide have been reported to reduce mortality only in severe acute pancreatitis in a single meta analysis[63],the current notion does not recommend their use in treatment with respect to cost-effectiveness.

Surgical treatment in acute pancreatitis

The role of surgical treatment in patients with pancreatic necrosis is still controversial. According to international consensus, surgical intervention in acute pancreatitis is only recommended for infected pancreatic necrosis[64-66].Surgical intervention should aim to remove all pancreatic tissues that cause the release of inflammatory mediators. For this purpose, various forms of necrosectomy and drainage methods, including surgical, radiological, endoscopic and minimally invasive, have been defined.

If the patient is clinically stable, surgical intervention is suitable after a 3-4 week of antibiotic therapy, decreased inflammatory reaction and reorganization of the infected region.

Radiological necrosectomy

The method was described by Freeny in 1998, and is based on the placement of thick percutaneous drainage catheters into the infected pancreatic tissue with the aid of CT. However, it does not result in very successful outcomes, and thus, is recommended for use in removing purulent fluid only in unstable patients in intensive care, and during patient’s surgical preparation[67].

Endoscopic necrosectomy

Endoscopic necrosectomy has found increased frequency in the treatment of pancreatic necrosis, fluid collections and pseudocysts, and has considerably high success rates. This technique has gained a place among the natural orifice endoscopic surgery(NOTES)methods. The main advantages of this method include that it does not require general anesthesia, its reproducibility, and it is minimally invasive[68].The major complications are bleeding, free perforation, gastric and duodenal fistules. Endoscopic ultrasonography, doppler imaging and scopy is relatively useful to prevent complications.

Minimally invasive necrosectomy

In recent years, less invasive methods have found a place as an alternative to open surgical interventions, especially in patients who do not have good overall conditions due to organ failure and comorbid diseases[69].In the first method; using percutaneous technique, the necrotic region is reached via nephroscope under CT, necrosectomy is performed, catheters are left for a long period for continuous irrigation, and continuous irrigation is performed with high-volume lavage. In the second method, drains with wide calibration are placed using laparoscopic necrosectomy and direct view[70].

Mild ABP does not leave clinically significant sequel in the long term.The incidence of late-term complications, such as delayed collections, pancreatic pseudocyst, biliary structure, persistent pancreatic fistula, gastrointestinal fistula, incisional hernia, pancreatic exocrine insufficiency and diabetes mellitus, may reach up to 60% in mild ABP.Therefore, long-term follow-up is required to monitor and manage the development of these late complications.

Endoscopic and Interventional Approaches in ABP

The suitable timing of cholecystectomy in ABP depends on the clinical course of the disease.In severe ABP with local and systemic complications, it may be recommended to postpone cholecystectomy after the resolution of these complications. The timing of cholecystectomy in mild ABPs which do not have local and systemic complications is controversial. While some studies recommend it at the time of admission [70,72],others recommend it two, three or four weeks after discharge from the hospital[72-74].

Other strategies, in addition to general precautions and medical treatment, are needed to improve the prognosis. Endoscopic treatment is one of these strategies. However, there is an ongoing discussion on the effect of early ERCP, which is performed between 24-72 hours, and sphincterotomy on the prognosis in cases with ABP[75]. Two metaanalysis on this topic have been published. One of these metaanalyses concluded that early ERCP had no positive effect on complication and mortality in mild or severe pancreatitis, whereas the other metaanalysisconcluded that early ERCP and sphincterotomy reduced complications rates in severe pancreatitis[76,77].The latest study on this topic belongs to the Netherlands acute pancreatitis research group[78].In this prospective, controlled study with 153 cases, the incidence of complications were lower in patients who had severe ABP and cholestatis(bilirubin>2.3 mg/dl and/or diameter of the common bile duct>8 mm) and who underwent early ERCP and sphincterotomy[5].In acute pancreatitis cases without cholestatis, the incidence of complications was similar between patients who received conservative treatment and patients who underwent ERCP. Common bile duct stoneshave been detected in approximately 50% of the cases with/without cholestatis, and similar incidence rates have been determined.In a study by Yeung et al., which involved 172 patients, routine ERCP was not suggested for mild ABP patients[79].

Early ERCP and sphincterotomy may reduce severe pancreatitis-dependent complication rates in selected cases. For the moment, ERCP and sphincterotomy should be recommended for cases with cholangitis, mild or severe pancreatitis with common bile duct stones determined by non-invasive methods, and severe pancreatitis with cholestatis findings, which do or do not have common bile duct stones. Differential diagnosis of cholangitis and pancreatitis can be difficultin patients who have severe pancreatitis and SIRS. In these patients, every effort including methods such as MRCP and EUS should be performed to demonstrate biliary obstruction before ERCP[80].First MRCP, and then EUS[81]can be performed to choose patients for ERCP[82,83].Pancreas, axtrahepatic biliary tracts and ampullary region can be evaluated in detail using EUS[81].

When bilayer drainage cannot be performed using ERCP/ES, endoscopic nasobiliary drainage or percutaneous transhepatic gallbladder drainage procedures can be performed alternatively[22].

In conclusion, the pathogenesis of ABP has not been fully elucidated and several theories have been suggested. Novel laboratory methods and scoring systems have been suggested for both diagnosis and to predict disease severity, and research on these topics is still in progress. Novel therapeutic approaches are also suggested with technological developments.

Competing interests

The authors declare that they have no competing interests.

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Orhan Veli Ozkan, Orhan Yagmurkaya, Erhan Sit. Contemporary Management of Acute Biliary Pancreatitis. J Clin Anal Med. 2015;6(6):799-806

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External Radiation Therapy Response in Kaposi’s Sarcoma

Vildan Kaya, İbrahim Çobanbaş, Alper Özseven

Süleyman Demirel University School of Medicine, Department of Radiation Oncology, Isparta, Turkey

DOI: 10.4328/JCAM.2495 Received: 15.04.2014 Accepted: 28.04.2014 Publihed Online: 28.04.2014

Corresponding Author: Vildan Kaya, Suleyman Demirel University School of Medicine, Department of Radiation Oncology, Isparta, Turkey. GSM: +905334797408 F.: +90 2462112832 E-Mail: vildansimsir@yahoo.com

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Abstract

Kaposi sarkomu hastalığı sıklıkla yaşamın 6. dekatında görülür…

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Kaposi sarkomu hastalığı sıklıkla yaşamın 6. dekatında görülür. Lokal tedavilere cevabı iyidir. Bu çalışmada, alt ekstremitede çok sayıda kaposi sarkomu lezyonu olan hastamızın radyoterapiye yanıtını sunmak istiyoruz. Kaposi Sarkomu (KS), Herpes virüs ailesinden HHV-8 ile ilişkili, lenfoproliferatif bir hastalıktır ve 4 temel varyantı vardır [1,2]. Klasik KS; 6. dekadda pik yapar. Sıklıkla alt ekstremite yerleşimli tek veya multipl, mor kırmızımsı ve kahverengi plaklarla nodüller bir arada görülür. Ağrı, kanama ve şekil bozukluğuna neden olabilir. Lenfödem ve hiperkeratozla birlikte de görülür [3]. Klasik KS, tekrarlama eğilimleri olmasına rağmen lokal tedavilere oldukça iyi cevap verir. Sağ ayak bileği medialinde ayak dorsal bölgesine uzanan eflatun rengi plaklar olan 86 yaşında bayan hastanın aynı zamanda sağ ayakta da ödem ve ağrı yakınması mevcuttu (Resim 1). Lezyona yönelik dikdörtgen şekilli plastik bir kap içinde su, bolus olarak kullanıldı. Hastanın tedavi pozisyonunda bilgisayarlı tomografi görüntüleri alındı. Bu görüntüler üzerine klinik hedef volüm ve risk altındaki normal dokular belirlenerek 3-Boyutlu konformal radyoterapi (RT) planlandı. İzosentrik alan tekniği ile 2,5 Gy/gün fraksiyon dozuyla, 12 fraksiyonda toplam 30 Gy eksternal RT uygulandı. RT sonrası 3. Ayda hastanın sağ ayak bileğindeki kaposi sarkomu lezyonları ve plak görünümlerinde kısmi bir gerileme elde edildi (Resim 2). Ayrıca sağ ayak bileği ve dorsalindeki ödem ve ağrıda tam palyasyon sağlandı. Eksternal RT, Klasik Kaposi Sarkomu’nun lokal tedavi yöntemleri içinde önemli bir rol oynamaktadır.

Kaynaklar

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3. Ruocco E, Ruocco V, Tornesello ML, Gambardella A, Wolf R, Buonaguro FM. Kaposi’s sarcoma: etiology and pathogenesis, inducing factors, causal associations, and treatments: facts and controversies. Clin Dermatol 2013;31(4):413-22.

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Vildan Kaya, Ibrahim Cobanbas, Alper Ozseven. External Radiation Therapy Response in Kaposis Sarcoma. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2495

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Spontaneous Regression of a Cervical Disk Herniation

Emre Delen

Edirne State Hospital, Dept. of Neurosurgery, Edirne, Türkiye

DOI: 10.4328/JCAM.2430 Received: 24.03.2014 Accepted: 28.04.2014 Publihed Online: 28.04.2014

Corresponding Author: Emre Delen, Edirne Devlet Hastanesi Beyin Cerrahisi Kliniği, Edirne, Türkiye. GSM: +905306144646 F.: +90 2845138305 E-Mail: emredelen1979@yahoo.com

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A 54 years old female patient was admitted to our outpatient clinic with a two months history of muscle spasms of her neck and pain radiating to the left upper extremity…

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A 54 years old female patient was admitted to our outpatient clinic with a two months history of muscle spasms of her neck and pain radiating to the left upper extremity. Magnetic resonance imaging had shown a large left-sided paracentral disk herniation at the C6-C7 disk space (Figure 1). Neurological examination showed no obvious neurological deficit. She received conservative treatment including bed rest, rehabilitation, and analgesic drugs. After 13 months, requested by the patient, a second magnetic resonance imaging study showed resolution of the disc herniation.(Figure 2) Although the literature contains several reports about spontaneous regression of herniated lumbar disc without surgical intervention, that of phenomenon reported for herniated cervical level is rare, and such reports are few[1]. In conclusion, herniated intervertebral disc have the potential to spontaneously regress independently from the spine level. With further studies, determining the predictive signs for prognostic evaluation for spontaneous regression which would yield to conservative treatment would be beneficial.

Reference

1. Kobayashi N, Asamoto S, Doi H, Ikeda Y, Matusmoto K. Spontaneous regression of herniated cervical disc. The Spine Journal 2003(3): 171–3.

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Emre Delen. Spontaneous Regression of a Cervical Disk Herniation. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2430

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Coexistence of Single Coronary Artery Anomaly and Aortic Arch Anomaly

Yılmaz Ömür Otlu 1, Serkan Öner 2, Şıho Hidayet 3

1 Department of Cardiology, Kars State Hospital, Kars, 2 Department of Radiology, Inonu University Faculty of Medicine, Malatya, 3 Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey

DOI: 10.4328/JCAM.2099 Received: 22.10.2013 Accepted: 03.11.2013 Publihed Online: 04.11.2013

Corresponding Author: Yılmaz Ömür Otlu, Department of Cardiology, Kars State Hospital, 36200 Kars, Turkey. T.: +90 4742125658 GSM: +905394743014 E-Mail: omurotlu@yahoo.com

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Journal of Clinical and Analytical MedicineTek Koroner Arter Anomalisi / Sigle Coronary Artery AnomalyYılmaz Ömür Otlu1, Serkan Öner2, Şıho Hidayet31Department of Cardiology, Kars State Hospital, Kars, 2Department of Radiology, Inonu University Faculty of Medicine, Malatya, 3Department of Cardiology, Inonu University Faculty of Medicine, Malatya, TurkeyCoexistence of Single Coronary Artery Anomaly and Aortic Arch AnomalyTek Koroner Arter Anomalisi ile Aortik Ark Anomalisi BirlikteliğiA 74-year-old male patient was admitted to our hospital for evaluation of recent onset atypical chest pain. His medical history included hypertension, dislipidemia and smoking. Physical examination was unremarkable…

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A 74-year-old male patient was admitted to our hospital for evaluation of recent onset atypical chest pain. His medical history included hypertension, dislipidemia and smoking. Physical examination was unremarkable. The resting electrocardiogram was demonstrated biphasic T waves on lateral derivations. Transthoracic echocardiography showed normal left and right ventricular dimensions and functions. Coronary angiography was planned for the patient. First, right transradial approach tried; but guidewire could not be advanced to ascendig aorta. Coronary angiography was performed through the right femoral artery. Multiple attempts to cannulate the left coronary ostium were unsuccessful. The right coronary artery cannulated from its normal ostium in the right sinus of Valsalva. After a very short common main stem, the artery divided into a right coronary artery, and separate left anterior descending artery and circumflex artery (Figure A). The coronary arteries were normal without any significant stenosis and any extrinsic compression. An aortic root injection confirmed the absence of left coronary ostium. Also, a retroesophageal right subclavian artery originating from the left aortic arch (arteria lusoria) was detected as the last branch of aortic arch on contrast enhanced computerized tomography (Figure B-C). The patient discharged with medical teraphy.

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Yilmaz Omur Otlu, Serkan Oner, Siho Hidayet. Coexistence of Single Coronary Artery Anomaly and Aortic Arch Anomaly. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2099

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A Diagnosis that Should be Kept in Mind; Diaphragmatic Rupture

Taner Tarladaçalışır, İlkay Albayrak

Edirne Devlet Hastanesi Göğüs Cerrahisi Kliniği, Türkiye

DOI: 10.4328/JCAM.2098 Received: 16.10.2013 Accepted: 02.11.2013 Publihed Online: 03.11.2013

Corresponding Author: Taner Tarladaçalışır, Edirne Devlet Hastanesi, Sarıcapaşa Mahallesi, Çukur Çeşme Sokak, No: 4-6 Ayşekadın, 22020, Edirne, Türkiye. T.: +90 2842145516 (Santral) – 1309 (Dahili) GSM: +905325239968 E-Mail: tanertarladacalisir@yahoo.com

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Journal of Clinical and Analytical MedicineDiyafragma Rüptürü / Diaphragmatic RuptureTaner Tarladaçalışır, İlkay Albayrak Edirne Devlet Hastanesi Göğüs Cerrahisi Kliniği, TürkiyeA Diagnosis that Should be Kept in Mind; Diaphragmatic RuptureAkılda Tutulması Gereken Tanı; Diyafragma Rüptürü Otuz yedi yaşında erkek hasta, kesici delici alet yaralanması sonucu başvurduğu hastanede çekilen toraks tomografisinde hemopnömotoraks tespit edilmesi üzerine, sol tüp torakostomi uygulanarak…

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Otuz yedi yaşında erkek hasta, kesici delici alet yaralanması sonucu başvurduğu hastanede çekilen toraks tomografisinde hemopnömotoraks tespit edilmesi üzerine, sol tüp torakostomi uygulanarak Göğüs Cerrahisi konsültasyonu açısından hastanemize sevk edilmiş. Hastanın yapılan muayenesinde sol 9. interkostal aralık orta aksiller hatta yaklaşık 2 cm’ lik, muhtemel kesici delici alet yaralanmasına ait sütüre kesi mevcuttu. Vital bulguları; kan basıncı 120/80 mmHg, nabız 88/dk, oksijen saturasyonu % 97 idi. Hemoglobin değeri 13 g/dL idi. Hastanın toraks dreni ossile idi, hava kaçağı yoktu, toraks şişesi 300 cc seviyesinde idi. Hastanın tomografisi tekrar incelendiğinde, yaralanma izdüşümüne uyan diafragma hattında defekt ve kostodiafragmatik sinüse uyan toraks alanında omental yağlı doku imajı (Hounsfield unit: -74) izlendi (Resim 1). Hastaya, batın tomografisinde batın içi serbest hava ve sıvı imajı izlenmediğinden laporotomi yerine lateral torakotomi uygulandı. Diyafragma lateralinde tespit edilen laserasyon alanı, herni redüksiyonunu takiben sütüre edildi. Klinik ve radyolojik takipleri sorunsuz seyreden hasta operasyon sonrası beşinci gün şifa ile taburcu edildi.

Genellikle eşlik eden problemlerin gölgesinde kalan diyafragma rüptürü, özellikle önde meme başı altı, sırtta skapula alt ucu seviyesinin altındaki toraks bölgesi yaralanmalarında akılda tutulmalıdır.

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Taner Tarladacalisir, Ilkay Albayrak. A Diagnosis that Should be Kept in Mind; Diaphragmatic Rupture. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2098

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A Case of Undesired Bleb Developed After Penetrating Injury

Cem Özgönül 1, Gökçen Gökçe 2

1 Anıttepe Jandarma Dispanseri, Göz Hast. Polikliniği, Ankara, 2 Sarıkamış Asker Hastanesi, Göz Hast. Servisi, Kars, Türkiye

DOI: 10.4328/JCAM.2102 Received: 17.10.2013 Accepted: 24.10.2013 Publihed Online: 25.10.2013

Corresponding Author: Cem Özgönül, Anıttepe Jandarma Dispanseri, Göz Hast. Polikliniği, Yücetepe Mh. Gençlik Cd. 88. Sk. Çankaya, Ankara, Türkiye. T.: +905555584436 E-Mail: cemozgonul@hotmail.com

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Journal of Clinical and Analytical MedicinePenetran Yaralanma Sonrası İstenmeyen Bleb / Undesired Bleb After Penetrating InjuryCem Özgönül1, Gökçen Gökçe21Anıttepe Jandarma Dispanseri, Göz Hast. Polikliniği, Ankara, 2Sarıkamış Asker Hastanesi, Göz Hast. Servisi, Kars, TürkiyeA Case of Undesired Bleb Developed After Penetrating InjuryPenetran Yaralanma Sonrası Gelişen İstenmeyen Bleb OlgusuSeksen yaşında erkek hasta her iki gözünde batma, yanma ve kaşıntı şikayetleri ile polikliniğimize başvurdu. Oftalmolojik muaye-nede, en iyi düzeltilmiş görme keskinliği Snellen eşeline göre sağ gözde 0,9, sol gözde 0,8 düzeyindeydi…

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Seksen yaşında erkek hasta her iki gözünde batma, yanma ve kaşıntı şikayetleri ile polikliniğimize başvurdu. Oftalmolojik muayenede, en iyi düzeltilmiş görme keskinliği Snellen eşeline göre sağ gözde 0,9, sol gözde 0,8 düzeyindeydi. Otorefraktometre ile sağda -1,00 diyoptri, solda -0,75 diyoptri miyopi mevcuttu. Biyomikrokopide; her iki gözde gözyaşı menisküsünün azalmış olduğu, konjonktivoşalazis mevcut olduğu, lens ön kapsülü ile pupil kenarında psödoeksfoliyasyon ve LOCS III sınıflamasına göre C0 N2 P0 düzeyinde kataraktı olduğu görüldü. İlave olarak sağ gözde nazal limbusta, saat 2-3 arası kadranda çevre kornea ve konjonktiva dokusu vaskülarize olan ancak üzerindeki epitelin avasküler olduğu, ön kamara ile ilişkili 3x3x3 mm boyutlarında istenmeyen bleb olduğu görüldü. Fundoskopi her iki gözde normal görünümdeydi. Göz içi basıncı Goldman aplanasyon tonometresiyle sağda 15 mmHg, solda 14 mmHg olarak ölçüldü. Bu bulgulara yönelik hasta sorgulandığında, 40 yıl önce traş makinesi ile sakal traşı olurken makine aksamından bir parçanın kırılarak gözüne girdiği ve o dönem bir kez ameliyat olduğu anamnezine ulaşıldı. Hastaya yapılan oküler ultrasonografide göz içi yabancı cisim saptanmadı. Hastaya suni gözyaşı damlası başlanarak takibe alındı.

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Cem Ozgonul, Gokcen Gokce. A Case of Undesired Bleb Developed After Penetrating Injury. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2102

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An Asymptomatic Saccular Aneurysm of Pulmonary Artery: A Rare Case of Solitary Pulmonary Nodule

Servet Kayhan 1, Ünal Şahin 1, Sabri Oğullar 2

1 Göğüs Hastalıkları AD, 2 Radyoloji Bölümü, Recep Tayyip Erdoğan Üniversitesi, Tıp Fakültesi, Rize, Türkiye

DOI: 10.4328/JCAM.2072 Received: 29.09.2013 Accepted: 13.10.2013 Publihed Online: 15.10.2013

Corresponding Author: Servet Kayhan, Recep Tayyip Erdoğan Üniversitesi, Tıp Fakültesi, Göğüs Hastalıkları AD, Rize Türkiye. T.: +905326717174 F.: +90 4642123015 E-Mail: servet-kayhan@hotmail.com

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Pulmonary artery aneurysm, especially the peripheral type, is a rare disease. We present an asymptomatic adult case whom had been underwent a series of correctional cardiovascular operations for Fallot tetralogy in her childhood period. A thirty year old female patient got a diagnosis of solitary pulmonary nodule (Figure 1). Contrast enhanced computed tomography (CT) and CT angiography revealed the aneurysm of posterior segment (A2 segment) of the right upper lobe artery (Figure 2 and 3). Prior to decision of diagnostic interventions, clinicians should be aware of an aneurysm of pulmonary artery can be a cause of peripheral solitary pulmonary nodules.

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Pulmonary artery aneurysm, especially the peripheral type, is a rare disease. We present an asymptomatic adult case whom had been underwent a series of correctional cardiovascular operations for Fallot tetralogy in her childhood period. A thirty year old female patient got a diagnosis of solitary pulmonary nodule (Figure 1). Contrast enhanced computed tomography (CT) and CT angiography revealed the aneurysm of posterior segment (A2 segment) of the right upper lobe artery (Figure 2 and 3). Prior to decision of diagnostic interventions, clinicians should be aware of an aneurysm of pulmonary artery can be a cause of peripheral solitary pulmonary nodules.

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Servet Kayhan, Unal Sahin, Sabri Ogullar. An Asymptomatic Saccular Aneurysm of Pulmonary Artery: A Rare Case of Solitary Pulmonary Nodule. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2072

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Bilateral Coronary Artery Fistulas Draining Into Pulmonary Artery

Yılmaz Ömür Otlu 1, Adil Bayramoğlu 2, Şıho Hidayet 3

1 Department of Cardiology, Kars State Hospital, Kars, 2 Department of Cardiology, Elbistan State Hospital, Kahramanmaraş, 3 Department of Cardiology, Inonu University Faculty of Medicine, Malatya, Turkey

DOI: 10.4328/JCAM.2036 Received: 27.08.2013 Accepted: 01.10.2013 Publihed Online: 03.10.2013

Corresponding Author: Yılmaz Ömür Otlu, Department of Cardiology, Kars State Hospital, Kars, Türkiye. T.: +90 4742125658 GSM: +905394743014 E-Mail: omurotlu@yahoo.com

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82 yaşında erkek hasta kliniğimize bir aydır mevcut, eforla ilişkisiz, batıcı karakterde göğüs ağrısı şikâyeti ile başvurdu. Hasta hipertansiyon tanısı ile yaklaşık 10 yıldır ramipril+hidroklorotiazid (2,5/12,5 mg) tedavisi almaktaydı. Kardiyovasküler sistem muayenesinde kan basıncı 125/85 mmHg ve kalp hızı 80 atım/dk olarak belirlendi. II. interkostal aralık – sternum sol kenarı bileşkesinde sistolik 2/6 üfürüm saptandı. Elektrokardiyografisinde patoloji saptanmayan hastada transtorasik ekokardiyografi sonucu normal sol ventrikül sistolik fonksiyonları, normal boyutlarda sağ ve sol kalp boşlukları, normal pulmoner arter çap ve akımı izlendi…

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82 yaşında erkek hasta kliniğimize bir aydır mevcut, eforla ilişkisiz, batıcı karakterde göğüs ağrısı şikâyeti ile başvurdu. Hasta hipertansiyon tanısı ile yaklaşık 10 yıldır ramipril+hidroklorotiazid (2,5/12,5 mg) tedavisi almaktaydı. Kardiyovasküler sistem muayenesinde kan basıncı 125/85 mmHg ve kalp hızı 80 atım/dk olarak belirlendi. II. interkostal aralık – sternum sol kenarı bileşkesinde sistolik 2/6 üfürüm saptandı. Elektrokardiyografisinde patoloji saptanmayan hastada transtorasik ekokardiyografi sonucu normal sol ventrikül sistolik fonksiyonları, normal boyutlarda sağ ve sol kalp boşlukları, normal pulmoner arter çap ve akımı izlendi. Treadmill egzersiz testinde hafif düzeyde atipik karakterde göğüs ağrısı olması üzerine test erken sonlandırıldı ve koroner anjiyografi planlandı. Koroner anjiyografide sol ön inen arter proksimal kesiminden (Şekil 1 A,B) ve sağ koroner arter proksimal kesiminden (Şekil 1 C) köken alıp pulmoner artere drene olan fistüller izlendi. Koroner arterlerde kritik düzeyde (>%50) aterosklerotik lezyon saptanmadı. Anjiyografi sonrası tekrar edilen ekokardiyografide Qp/Qs oranı 1,2 olarak hesaplandı. İskemi taraması için yapılan miyokard perfüzyon sintigrafisi sonucu iskemik alan saptanmadı. Hastanın kalp boşluklarının normal boyutlarda olması, ekokardiyografik değerlendirmede ciddi şant bulgusunun olmaması, sintigrafi sonucu iskemi saptanmaması ve göğüs ağrısının atipik olması sebebi ile semptomların koroner arter fistüllerine bağlı olmadığı sonucuna varıldı. Hastaya işlem uygulanmaması ve klinik izlemine karar verildi.

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Yilmaz Omur Otlu, Adil Bayramoglu, Siho Hidayet. Bilateral Coronary Artery Fistulas Draining Into Pulmonary Artery. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2036

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Letter to Editor

Rare Complication of Tube Thoracostomy: Horner’s Syndrome

Fatih Hikmet Candaş

GATA Haydarpaşa Eğitim Hastanesi, Göğüs Cerrahisi Servisi, İstanbul, Türkiye

DOI: 10.4328/JCAM.2459 Received: 04.04.2014 Accepted: 04.04.2014 Publihed Online: 08.04.2014

Corresponding Author: Fatih Hikmet Candaş, GATA Haydarpaşa Eğitim Hastanesi, Göğüs Cerrahisi Servisi, 34668, Üsküdar, İstanbul, Türkiye. GSM: +905053295326 E-Mail: fhcandas@yahoo.com

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Editör için:Derginizde published online olarak yayınlanan “Göğüs Tüpünün Nadir Komplikasyonu: Horner Sendromu” başlıklı Sayın Çelik ve ark. [1] tarafından yazılan olgu sunumunu ilgiyle okudum. Bu konuyla ilgili bir kaç noktaya temas etmek istiyorum…

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Editör için:

Derginizde published online olarak yayınlanan “Göğüs Tüpünün Nadir Komplikasyonu: Horner Sendromu” başlıklı Sayın Çelik ve ark. [1] tarafından yazılan olgu sunumunu ilgiyle okudum. Bu konuyla ilgili bir kaç noktaya temas etmek istiyorum.

Çelik ve ark. [1], aşırı el terlemesi nedeniyle bilateral torakal sempatektomi uyguladıkları olgularına bilateral tüp torakostomi yerleştirerek ameliyatlarını sonlandırmışlar ve olgularında postoperatif birinci günde sağ Horner sendromu saptamışlardır. Horner sendromunun nedenini ise apikal yerleşimli toraks tüpünün stellat gangliyona basısına bağlı olarak geliştiğini, drenin geri çekildiğini ve 10 gün içinde semptomların düzeldiğini bildirmişlerdir.

Servikotorasik gangliyon olarak da tanımlanan stellat gangliyon genellikle inferior servikal gangliyon ve torakal (T) 1. sempatik gangliyonun birleşmesinden oluşmaktadır. Yapılan kadavra çalışmalarında stellat gangliyonun insidansı %75-88 arasında bildirilmiş olup %65 oranında ise bilateral görülebilmektedir [2]. Stellat gangliyonun yapısına %5 oranında T2 sempatik gangliyon da katılabilmektedir [3]. Bu nedenle torakal sempatektomi uygulanacak olan hastalarda T2 sempatik gangliyona müdahale edilecekse Horner sendromu açısından dikkatli olunmalıdır.

Çelik ve ark. [1] da bildirdiği gibi stellat gangliyon ile paryetal plevra arasında ince bir bağ dokusu olan endotorasik fasiya bulunur. Bu nedenle apikal yerleşimli toraks tüpü, solunumsal hareketlerin de etkisiyle stellat gangliyonda oluşturduğu travma sonrası Horner sendromu geliştirebileceği gibi [4], spontan pnömotoraksa bağlı Horner sendromu gelişebileceği de bildirilmiştir [5].

Kaya ve ark. [6] yalnızca tüp torakostomi uyguladıkları 662 hastanın 5’inde (%0,8) Horner sendromu saptamışlardır. Koçer ve ark. [7] ise uyguladıkları 626 tüp torakostomi girişiminde Horner sendromu saptamadıklarını bildirmiş olup bu durumu tüp torakostomi sırasında omuz ağrısı gelişen hastalarda tüpü biraz geri çekerek tespit etmelerine bağlamışlardır.

Thomas ve ark. [4] iki olgularını da sundukları literatür taramasında, tüp torakostomiye bağlı Horner sendromu gelişen toplam 24 olgunun semptomlarının dağılımını; %91.3 pitozis, %58.3 miyozis, %30.4 anhidroz, %21.7 anizokori, %17.4 enoftalmus olarak bildirmişlerdir. Olguların %45.8’inde, kısmi (%25) ve tam (%20.8) olmak üzere sekel kaldığını saptamışlardır. Yaptıkları literatür taramasında üç olguda ise tüp torakostominin sonlandırılmasından sonra Horner sendromu geliştiğini, bu durumu da tekrarlayan travmaya bağlı olarak geç gelişen skar dokusu nedeniyle oluşabileceğini ifade etmişlerdir.

Sonuç olarak; tüp torakostomiye bağlı gelişen Horner sendromu vakalarının yaklaşık yarısında tam veya kısmi sekel kaldığı da göz önünde bulundurulursa, toraks tüpünün gerekli olmadıkça apekse kadar ilerletilmemesi, aksi durumda muhtemel gelişebilecek olan komplikasyoları engelleyebilmek amacıyla bir miktar geri çekilmesi veya tekrar pozisyon verilmesi daha uygun olacaktır.

Nadir fakat kalıcı sekellere neden olabilecek olgu örneğini bizlerle paylaştıkları için Sayın Çelik ve arkadaşlarına teşekkür eder, saygılarımı sunarım.

Kaynaklar

1. Çelik B, Gürz S, Pirzirenli MG, Sürücü ZP. Göğüs Tüpünün Nadir Komplikasyonu: Horner Sendromu. J Clin Anal Med. DOI: 10.4328/JCAM.2311

2. Pather N, Partab P, Singh B, Satyapal KS. Cervico-thoracic ganglion: its clinical implications. Clin Anat. 2006;19(4):323-6.

3. Singh B, Ramsaroop L, Partab P, Moodley J, Satyapal KS. Anatomical variations of the second thoracic ganglion. Surg Radiol Anat. 2005;27(2):119-22.

4. Thomas DT, Dagli TE, Kiyan G. Horner’s syndrome as a rare complication of tube thoracostomy: case reports and review of literature. J Pediatr Surg. 2013;48(6):1429-33.

5. Mutalib M, Vandervelde C, Varghese A, et al. Horner’s syndrome secondary to asymptomatic pneumothorax in an adolescent. Eur J Pediatr. 2007;166(5):507-8.

6. Kaya SO, Liman ST, Bir LS, Yuncu G, Erbay HR, Unsal S. Horner’s syndrome as a complication in thoracic surgical practice. Eur J Cardiothorac Surg. 2003;24(6):1025-8.

7. Koçer B, Gülbahar G, Yıldırım E, Dural K, Sakıcı Ü. Tüp Torakostominin 603 Hastadaki Komplikasyonları. Turkiye Klinikleri J Med Sci 2010;30(3):895-9.

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Fatih Hikmet Candas. Rare Complication of Tube Thoracostomy: Horners Syndrome. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2459

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Anesthesia in Transrectal Ultrasound Guided Biopsy

Memduh Yetim 1, Oğuz Kılıçkaya 2

1 Anestezioloji, Van Asker Hastanesi, Van, 2 Anest. ve Rean. A.D. GATA, Ankara, Türkiye

DOI: 10.4328/JCAM.2565 Received: 16.05.2014 Accepted: 18.05.2014 Publihed Online: 20.05.2014

Corresponding Author: Memduh Yetim, Anestezioloji, Van Asker Hast. Tuşba, Van, Türkiye. GSM: +905322046799 F.: +90 4623221930 E-Mail: memduhyetim@yahoo.com

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Editör için:Kürşat Zengin ve ark.’nın “Transrektal Ultrason Eşliğinde Prostat Biyopsisinde İki Farklı Anestetik Metodun Karşılaştırılması” ko-nulu orjinal araştırmasını büyük bir ilgiyle okuduk [1]…

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Kürşat Zengin ve ark.’nın “Transrektal Ultrason Eşliğinde Prostat Biyopsisinde İki Farklı Anestetik Metodun Karşılaştırılması” konulu orjinal araştırmasını büyük bir ilgiyle okuduk [1]. Araştırmada transrektal ultrason eşliğinde prostat (TRUSP) biyopsisinde periprostatik sinir blokajı (PPSB) ve perianal-intrarektal lokal anestezik tatbikinin hasta ağrı düzeyine etkileri retrospektif olarak karşılaştırılmış. Klinik uygulama açısından önemli olan bu konu, başarılı tasarımı ve dökümantasyonu ile bizimle paylaşılmış.

Prostat kanseri erkek popülasyonda görülen en sık kanserlerden biridir ve TRUSP-biyopsisi tanıda standart bir prosedürdür [2,3]. TRUSP-biyopsisinde hasta konforunu ve memnuniyetini arttırmak için farklı anestezik teknikler kullanılmaktadır. PPSB sık kullanılan, kolay uygulanabilen ve ağrı kontrolünde etkin bir anestezik yöntemdir [4]. Perianal-intrarektal lokal anestezik uygulaması uygulama bakımından en kolay yöntem olmasına karşın hastada ağrı kontrolü açısından çok başarılı değildir.

VAS (Görsel Analog Skala), hastanın ağrısını değerlendirmede en sık kullanılan ağrı ölçeğidir. Çalışmada hastanın ağrı düzeyleri karşılaştırılırken VAS kullanılmış, fakat girişimin farklı evreleri için ayrı ayrı bakılmamış. İşlem sırasında ağrı, ultrason probu yerleştirilirken anüs dilatasyonu sırasında ve biyopsi iğnesinin prostat kapsülünü delmesi sırasında oluşmaktadır. Çalışmada bu evrelerin her biri için VAS skorunun ayrı ayrı değerlendirilmesi ve VAS değerlendirmelerinin postoperatif süreçte de sürdürülmesi, özellikle, işlemden ne kadar sonra hastada analjezi gereksinimi olduğunun kaydedilmesi yapılan bloğun etkinliğini göstermesi açısından okuyucuyu daha fazla bilgilendirebilirdi. Ayrıca subjektif bir değerlendirme ölçeği olan VAS sorgulamasının retrospektif yapılması da değerlendirmenin sağlıklı olma ihtimalini azaltmaktadır. Sonuç olarak bu TRUS-biyopsisinde VAS değerlerinin ve hasta memnuniyetinin prospektif olarak, girişimin her bir evresinde ve girişim sonrasında ayrı ayrı değerlendirilmesinin ve girişim sonrası analjezik gereksinimlerinin karşılaştırılmasının okuyucuyu daha doğru bir şekilde yönlendireceğine inanıyoruz.

Kaynaklar

1. Zengin K, Tanık S, Albayrak S, Bakırtaş H, İmamoğlu MA, Gürdal M. Transrektal ultrason eşliğinde prostat biyopsisinde iki farklı anestetik metodun karşılaştırılması. J Clin Anal Med 2015; DOI: 10.4328/JCAM.2335

2. Autorino R, De Sio M, Di Lorenzo G, Damiano R, Perdonà S, Cindolo L, D’Armiento M. How to decrease pain during transrectal ultrasound guided prostate biopsy: a look at the literature. J Urol 2005;174(6):2091-7.

3. Ceylan C, Ceylan T, Odabaş Ö, Yüksel S, Doğan S, Yiğman M. Türk erkeklerinde prostat kanseri tanisinda transrektal ultrasonografi ve rektal muayenenin rolunun değerlendirilmesi. J Clin Anal Med 2012;3(2): 170-3

4. Seymour H, Perry MJA, Lee-Elliot C, Dundas D, Patel U. Pain after transrectal ultrasonography-guided prostate biopsy: the advantages of periprostatic local anaesthesia. BJU Int 2001;88 (6):540-4.

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Memduh Yetim, Oguz Kilickaya. Anesthesia in Transrectal Ultrasound Guided Biopsy. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2565

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Is Surgical Biopsy Necessary for Diagnosis of Interstitial Lung Diseases: A Retrospective Clinical Study

Fatih Candaş

GATA Haydarpaşa Eğitim Hastanesi, Göğüs Cerrahisi Servisi, Üsküdar, İstanbul, Türkiye

DOI: 10.4328/JCAM.2498 Received: 17.04.2014 Accepted: 17.04.2014 Publihed Online: 18.04.2014

Corresponding Author: Fatih Candaş, GATA Haydarpaşa Eğitim Hastanesi, Göğüs Cerrahisi Servisi, 34668, Üsküdar, İstanbul, Türkiye. GSM: +905053295326 E-Mail: fhcandas@yahoo.com

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Editör için:Fındıkcıoğlu ve ark. [1] tarafından kaleme alınan ve derginizin Mayıs 2014 sayısında yayınlanan “İnterstisyel Akciğer Hastalıkla-rında Cerrahi Biyopsi Gerekli midir: Retrospektif Klinik Çalışma” başlıklı makaleyi ilgiyle okudum…

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Fındıkcıoğlu ve ark. [1] tarafından kaleme alınan ve derginizin Mayıs 2014 sayısında yayınlanan “İnterstisyel Akciğer Hastalıklarında Cerrahi Biyopsi Gerekli midir: Retrospektif Klinik Çalışma” başlıklı makaleyi ilgiyle okudum. Bu konuyla ilgili olarak İnterstisyel Akciğer Hastalıklarında (İHA) uygulanan cerrahi prosedürler hakkında birkaç noktaya temas etmek istiyorum.

Fındıkcıoğlu ve ark. [1] İHA ön tanısıyla VATS ve torakotomi ile olmak üzere toplam 45 hastaya biyopsi ameliyatı uyguladıklarını; cerrahi sonrası VATS grubunda morbiditeyi %16 (5/31), mortaliteyi %6 (2/31) oranında; torakotomi grubunda ise morbidite saptamayıp mortaliteyi ise %14 (2/14) oranında saptadıklarını bildirmişlerdir. Cerrahi sonrası patolojik tanı oranını ise %82 olarak vermişlerdir. Çobanoğlu ve ark. [2] ise aynı amaçla 31 hastaya VATS ve torakotomi ile uyguladıkları biyopsi ameliyatlarında mortalite gözlemeyip morbidite oranlarını ise VATS grubunda %8 (1/12) ve torakotomi grubunda %16 (3/19) olarak belirtmişlerdir. Cerrahi sonrası patolojik tanı oranı ise %80 (25/31)’dir. Bu serilerde VATS’ın torakotomiye göre operasyon ve yatış süresi açısından üstün olduğunu, komplikasyon ve tanı değeri açısından ise istatistiksel anlamlı fark olmadığını, sonuçların literatür ile uyumlu olduğunu bildirmişlerdir.

Diğer taraftan İAH nedeniyle biyopsi ameliyatı uygulanacak olan ve hastalıkları nedeniyle de genel anestezinin risk ve komplikasyonlarına yatkın olan bu hastalarda, risk ve komplikasyonları azaltmak amacıyla, uygun olan hastalarda genel anestezi vermeden bölgesel anestezi eşliğinde VATS ile biyopsi ameliyatları yapıldığı Pompeo ve ark. [3] tarafından bildirilmiştir. Otuz olguluk bu çalışmada entübasyon uygulanmadan 10 hastaya interkostal blok ve 20 hastaya epidural anestezi eşliğinde VATS ile biyopsi ameliyatı uygulanmış, epidural anestezi alan bir hastada plevral yapışıklıklar nedeniyle genel anesteziye geçilmeden lateral torakotomi yapılarak biyopsi alınmıştır. Bu seride, bir hastada atelektaziye sekonder gelişen ateş dışında majör komplikasyon ve mortalite saptanmamış olup cerrahi sonrası patolojik tanı oranı ise %97 (29/30) olarak verilmiştir.

Bu bilgiler ışığında İHA nedeniyle biyopsi uygulanacak hastalarda, postoperatif mortalite, morbidite ve cerrahi sonrası patolojik tanı oranlarında birbirlerine üstünlüğü olmayan VATS ve torakotomi prosedürlerinden öncelikle daha az invaziv metod olan VATS kullanılması, uygun olan hastalarda ise genel anestezinin de yan etkilerini azaltmak için bölgesel anestezi eşliğinde VATS ile biyopsi alınmasının hastalar açısından daha yararlı olabileceği kanaatindeyim.

Çalışmalarını bizlerle paylaştıkları için Sayın Fındıkcıoğlu ve arkadaşlarına teşekkür ederim.

Kaynaklar

1. Fındıkcıoğlu A, Kılıç D, Karadayı Ş, Canpolat T, Hatipoğlu A. İnterstisyel Akciğer Hastalıklarında Cerrahi Biyopsi Gerekli Midir: Retrospektif Klinik Çalışma. J Clin Anal Med 2014;5(3): 204-8.

2. Çobanoğlu U, Sayır F, Mergan D. İnterstisyel Akciğer Hastalıklarının Tanısında İdeal Bir Tercih: Video Yardımlı Torakoskopik Cerrahi. J Clin Anal Med 2012;3(1):46-50.

3. Pompeo E, Rogliani P, Cristino B, Schillaci O, Novelli G, Saltini C. Awake Thoracoscopic Biopsy of Interstitial Lung Disease. Ann Thorac Surg 2013;95:445–52.

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Fatih Candas. Is Surgical Biopsy Necessary for Diagnosis of Interstitial Lung Diseases: A Retrospective Clinical Study. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2498

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Relationship Between Vesicoureteral Reflux and Detrusor Overactivity

Orçun Çelik 1, Tümay İpekçi 2, Mustafa Burak Hoşcan 2

1 İzmir Tepecik Education and Research Hospital, Department of Urology, İzmir, 2 Başkent University, Faculty of Medicine, Department of Urology, Alanya Practice and Research Center, Alanya, Turkey

DOI: 10.4328/JCAM.2460 Received: 04.04.2014 Accepted: 04.04.2014 Publihed Online: 08.04.2014

Corresponding Author: Mustafa Burak Hoşcan, Baskent University Alanya Research and Practice Center, Department of Urology Alanya, Antalya, Turkey. GSM: +905324364855 F.: +90 2425115563 E-Mail: drburakhoscan@yahoo.com

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Editör için:İdiyopatik detrüsör aşırı aktivitesi ile vezikoüreteral reflü derecesi arasındaki ilişkiyi değerlendirmeyi amaçlayan çalışmayı ilgi ile okuduk [1]…

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İdiyopatik detrüsör aşırı aktivitesi ile vezikoüreteral reflü derecesi arasındaki ilişkiyi değerlendirmeyi amaçlayan çalışmayı ilgi ile okuduk [1].

Vezikoüreteral reflü (VUR) ve alt üriner sistem disfonksiyonu (AÜSD) arasındaki ilişki Avrupa Üroloji Birliği kılavuzunda da belirtildiği gibi hem tanı hem de tedavi yönetimi açısından birbiri ile sıkı ilişki içinde olmasına rağmen aralarındaki bağı destekleyen kuvvetli çalışmalar yoktur [2].

Çalışmaların çoğu tanımlayıcı, kontrol grubu olmayan ve retrospektif olup kanıt düzeyi düşüktür. Son zamanlardaki güncel çalışmalardan İsveç reflü grubunun verilerine göre VUR ve AÜSD beraberliği olan çocuklarda tedavi sonucu diğerlerine göre özellikle böbrek hasarı açısından daha kötü olduğu saptanmıştır [3] .

AÜSD olan çocuklarda VUR sıklıkla düşük dereceli olup, ultrasonografi bulguları normaldir. Bu nedenle AÜSD olan tüm çocuklarda voiding sistoüretrografi yapma endikasyonu bulunmamaktadır. AÜSD olan çocuklarda ateşli idrar yolu enfeksiyonu öyküsü mevcutsa VUR saptanma olasılığı yüksek olacağı için video ürodinami çalışması yapılmalıdır. AÜSD tedavisi başarısız olan çocuklarda ürodinamik değerlendirme yapılmalıdır. Özellikle güncel literatürde yazarlarında belirttiği gibi detrüsör aşırı aktivitesi ve VUR arasında ilişkiyi gösteren kesin çalışmalar olmamakla birlikte ürodinamik inceleme ve voidingsistoüretrografi yapılması üzerinde durulmaktadır [4] .

Kaynaklar

1. Kılınç F, Is the Grade of Vesicoureteral Reflux Related with Detrusor Overactivity? J Clin Anal Med 2014;5(4):273-5.

2. Tekgül S, Riedmiller H, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, et al. EAU Guidelines on Vesicoureteral Reflux in Children. Eur Urol 2012;62:534–542.

3. Sillén U, Brandström P, Jodal U, Holmdahl G, Sandin A, Sjöberg I, et al. The Swedish reflux trial in children: v. Bladder dysfunction. J Urol 2010;184:298–304.

4. Colen J, Docimo SG, Stanitski K, Sweeney DD, Wise B, Brandt P, et al. Dysfunctional elimination syndrome is a negative predictor for vesicoureteral reflux. J Pediatr Urol 2006;2:312–5.

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Orcun Celik, Tumay Ipekci, Mustafa Burak Hoscan. Relationship Between Vesicoureteral Reflux and Detrusor Overactivity. J Clin Anal Med. 2015;6(6): 10.4328/JCAM.2460

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