Supplement 1 2022
Effect of fluoroscopy in central vein catheterization in children
Nevin Aydın 1, Osman Esen 2, Gülseren Yılmaz 1
1 Department of Anesthesiology and Reanimation, University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, 2 Department of Anesthesiology and Reanimation, Vocational School Of Health, Istinye University, Istanbul, Turkey
DOI: 10.4328/ACAM.20944 Received: 2021-11-10 Accepted: 2021-12-14 Published Online: 2021-12-19 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S1-5
Corresponding Author: Osman Esen, Zümrütevler Mahallesi, Handegül Sokak, No:98/16, Maltepe, İstanbul, Turkey. E-mail: email@example.com P: +90 505 677 13 85 F: +90 216 457 38 00 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6280-5064
Aim: In this study, we aimed to evaluate the effect of fluoroscopy on the prevention of malposition during placement of central venous catheters (CVC) in children, complications that occur during the procedure and follow-up and associated risk factors.
Material and Methods: A total of 87 central venous catheter placement procedures performed in 59 pediatric patients under fluoroscopy between 2014 and 2016 were included in the study. Demographic data, catheter insertion site, indication, number of attempts, catheter diameter, insertion time, complications during insertion and follow-up were recorded.
Results: The mean age of the cases was 5 months (1-28 months), and the mean body weight was 4.64 kg (1-14). Catheter insertions were mostly performed through the jugular vein. The femoral location was used in emergency situations in 12 patients (13.7%); 36.8% of catheter placements were used to provide peripheral vascular access, 59.8% were used for parenteral nutrition, intravenous fluid and inotropic support, and 3.4% for chemotherapy.
Complications occurred during catheter placement in 29 of the patients. The most common intervention complication was arterial puncture. Complications in the right jugular and subclavian regions were more common than in other regions (p=0.015). Malposition or kinking of the catheter was not observed during the placement. Arterial puncture and pneumothorax/hemothorax were encountered more frequently as the number of attempts increased (p= 0.001). Catheter-related bloodstream infection was the most common complication and was observed in 11 (12.6%) catheters.
Discussion: Various complications may be encountered during placement and monitoring in CVC applications in pediatric patients. Using fluoroscopy during placement reduces complications such as malposition and arrhythmia.
Keywords: Child, Catheterization, Fuoroscopy
Central venous catheter application has been playing an important role in monitorization and treatment of the patients in critical condition. CVC is a method used for interventional operations such as hemodynamic monitoring, liquid and medicinal applications in situations necessitating long-term follow-up and wide vascular access like chemotherapy, infusion of blood and blood components, parenteral nutrition, hemodialysis and plasmapheresis [1-3]. Subsequent to successful applications on adults, because of additional advantages CVC has brought to pediatric patients, its scope of utilization and application has been broadened. Whereas the complications may lessen when applied by experienced personnel, life- threatening complications may be encountered. Catheter placement intervention (operation) should be conducted by experienced staff in a sterile environment; complications, which may emerge during the operation and monitorization must be taken into consideration, and the catheter must be maintained carefully. In this study, it was aimed to evaluate emerging complications during the placement of central venous catheters guided by fluoroscopy, and during their monitoring in pediatric patients; and also assessment of related risk factors and effects of utilizing fluoroscopy on preventing malposition in CVC applications.
Material and Methods
Following the ethics committee approval, 87 central venous catheter insertion incidences and 59 pediatric patients subject to these applications between 2014-2016 in Kanuni Sultan Süleyman Training and research hospital anesthesiology and reanimation clinic, were evaluated retrospectively. For all the patients catheterized, age, weight, location of the insertion, number of insertions, the diameter of the catheter, the clinic where patient of concern is monitored, indications of insertion and removal of catheter, period of catheterization, complications during the insertion and catheterization process have been recorded.
Catheter complications were divided into two groups: Complications that emerged during insertion, and complications emerged during monitorization. Complications that emerged during insertion were assessed according to subtopics as arterial puncture, pneumothorax/hemothorax, malposition, and other complications (arrhythmia etc.); whereas complications that emerged during monitorization were evaluated for such subtopics as infection, thrombosis, catheter dysfunction, and other complications (hydrothorax etc.).
Subclavian vein, internal jugular vein and femoral vein were preferred for catheterization. All the catheters were applied in the operation room by two experienced anesthesiology and reanimation specialists through fluoroscopic guidance. All patients were sedated and anesthetized prior to the insertion, and all were intubated during the operation. For skin antisepsis, the location of insertion was wiped with 70% alcohol and sterilized with 10% povidone-iodine. The area of intervention was covered with a sterilized cloth. Personnel conducting the operation used mask, bonnet, and sterilized gown.
During the intervention, in addition to the physician realizing the operation, the patients were monitored by another anesthesiology and reanimation specialist with respect to hemodynamics and oxygenation. All the catheters were inserted under fluoroscopic guidance with landmark technique and seldinger method. According to the body weight of the subjects 4F, 5F, and 5.5F double-lumen temporary central venous catheters were used. After catheter location was immobilised by suture, it was covered with a transparent poliurethane cloth free of chlorhexidine, and the location was treated with medical dressing daily. After failing interventions, catheter insertion has been applied from a different location. Incidents where none of the locations could be catheterized were evaluated as unsuccessful. None of the patients were applied cut-down.
For catheter intervention, thrombocyte and normal prothrombin over 50.000/mm3, partial thromboplastin time, and INR were considered as prerequisites. In patients who can not meet the conditions, but have been in need for urgent catheterization, the femoral region was the primary location of choice. For subclavian and jugular catheters, the area between the superior vena cava and right atrium, whereas for femoral catheters, inferior vena cava had been acknowledged as the appropriate locations for placement. Once the location has been confirmed and has been tested for complications, catheter was stabilized. For patients catheterized more than two days, the growth of pathogens in one or more blood cultures obtained from the third day of insertion to one day after the catheter extraction, without any relation to other infection sources, provided that one of the symptoms of fever (>38 C), trembling or hypotension is present in the patients of any age, whereas one of the symptoms of fever (>38 C), hypothermia (<36 C), apnoea or bradycardia is present in the patients with ages less than one year and that the positive lab results are related to no other infection source; has been considered as “blood stream infection related to catheterization”. Since the study has been retrospective, catheter entry infection and tunnel infection could not be assessed.
The SPSS statistics program (IBM SPSS Statistics for Windows Version 16.0, SPSS Inc., and Chicago, IL, USA) was utilized. In evaluation, parametric numerical data were presented as mean ± standard deviation, whereas non-parametric numerical data were given as median (minimum-maximum). Categorical data were given as (%). The Chi-square test was used in evaluating the qualitative data. In the assessment of quantitative data, the Mann-Whitney U or Student T-test was utilized in case of homogeneity between the two groups; whereas the One Way Anova test was used for comparison of more than two groups. For all data concerned, p< 0,05 was considered statistically significant.
Pediatric patients were inserted CVC guided by fluoroscopy for 24 months. During this period, 87 central venous catheter interventions were realized by Anesthesiology and Reanimation Clinic on 56 pediatric patients. Fifteen (26,7%) of these patients had been catheterized recurrently. Catheters were applied to 41 patients in the neonatal intensive care unit, 32 patients in the pediatric department, 4 patients in the pediatric surgery department, and 2 patients in the neurosurgery department (Figure 1).
All 87 catheter interventions were successful. Among them, 45 (51,7%) were applied on the right-hand side of the body, whereas 42 (48,3 %) were inserted on the left-hand side. Twelve (13,7%) of the catheter interventions were realised on patients under emergency conditions with a thrombocyte number less than 50.000/mm3 (4 patients) and with high INR values (8 patients). In all these interventions, femoral location was preferred. For preventing hemorrhage in the catheter perimeter after the insertion, pressure was exerted after the application for control purposes. The average age of the catheterized patients was 5 months (1-28 months), and their average body weight was 4,64 (1-14) kg. Six (7%) of the interventions were applied from the femoral vein, 36 (41%) from the subclavian vein (34 from infraclavicular, 2 from supraclavicular area), 45 (52%) from the jugular vein.
Of all the catheter interventions 32 (36,8%) were for establishing peripheric vascular access, 52 (59,8) were for total parenteral nutritional intravenous liquid and inotrope support, 3 (3,4%) were for chemotherapy purposes. In 41,4% (36) of the patients 4F, 16,1% (14) 5F, and in 42,5% (37), 5,5F two lumen catheters have been applied.
Complications emerging during the operation were evaluated in subtopics as malposition, pneumothorax, arterial puncture and others (arrhythmia etc.). In 29 of the 87 catheter interventions, complications have emerged during insertion. The most frequent intervention complication was arterial puncture, which has been succeeded by pneumothorax in 3 (3,5%) patients. No malposition and catheter contortion have been observed during the operations. Patient’s age, body weight, number of interventions and the location of catheterization were assessed as risk factors with respect to the development of intervention complications. With regard to age, no statistically significant difference was observed between the group with intervention complications and the group with no complications (p:0,25). A statistically significant difference was established in terms of body weight, number of interventions, and the location of catheterization (Table 1). When the catheter locations were evaluated for the occurrence of interventional complications, a statistically significant difference was detected. Complications were encountered more frequently in the right jugular and left subclavian areas (p=0,015). Among operational complications, arterial puncture, pneumothorax/hemothorax was encountered more frequently as the number of interventions increased (p:0,001). It has been established that operational complications increase as the body weight increases.
Complications, which have emerged during monitorisation were evaluated in subtopics as infection, thrombosis, and other (hemothorax, hydrothorax). With regard to the development of infections during catheter monitorisation, catheterisation period and the lumen diameter of the catheter were considered risk factors. Accidental removals and occlusion of the catheters were not evaluated in complications category. During monitorisation, out of 87 inserted catheters, complications were encountered on 21 (24,1%) of them. No statistically significant difference has been established with regard to the parameters of monitorisation risk factor between the group with infection and the group with no infection (Table 2).
Catheter-related blood stream infection was the most frequent complication during monitorisation. Infection was observed on 11(12,6%) out of 87 catheters. Leukocyte count, catheter diameter, catheter’s period of stay, and insertion location have been evaluated as risk factors in the development of blood stream infection related to catheterization. No significant relations were established between infection development and these parameters (p>0,05). Since the study was conducted retrospectively, although blood cultures collected from the catheters were inspected for growth in patients with catheter- related blood stream infection, the microorganisms causing the infection and the existence of catheter entry point infection could not have been assessed. Thus, this constitutes the missing point of our research. Results of catheterization applications were as follows: in 17(19%) incidences, they were no longer needed, in 14 (16%) incidences, they were occluded, in 1 incidence, there was marginal leakage, in 1 another pneumothorax developed later, and in 21 (24,1) of the incidences catheters came off by spontaneous accidents. Twelve catheters were removed because the patients were deceased, and three catheterized patients were transferred to another health center. While there were no statistically significant differences between the catheter locations with regard to accidental withdrawals (p:0,47), they were proportionally encountered more frequently in subclavian areas.
In our study, 36,7% of central venous catheterizations were applied, since peripheric vessel catheterization was not possible. Whereas in similar studies, the most frequent reason for this application is peripheric vessel catheterization. We consider that, since the applications were realized by anesthesiology and reanimation specialists, peripheric vessel catheterization operations have been successful, so that there has been no need for central venous catheterisation [4,5]. Furthermore, we suggest that a high success rate in catheterisation is due to experienced operators, and that interventions have been realized in OR conditions under sedoanalgesia with fluoroscopic guidance.
Patient’s specifics and clinical experience of the operator should be taken into consideration while choosing catheter location. For every location to be chosen for catheterization there are distinctive advantages and disadvantages as well. While the subclavian and internal jugular locations carry less infection and thrombosis risk in extended uses, femoral location is safer with regard to mechanical complications. Moreover, it is more difficult to control hemorrhage in the subclavian area because of anatomical reasons [6-8]. In our hospital, most frequently utilized veins were subclavian vein 45 (51,7%), internal jugular vein 36 (41,4%), and femoral vein 6 (6,9%) consecutively. Although femoral location has been preferred by less experienced departments , based on the experience of specialists, subclavian vein has been utilised in our department because patient comfort is better and the existence of a shock does not affect the ratio of success, in spite of the fact that the intervention is technically harder and life-threatening complications are encountered more frequently. Ergül et al. preferred femoral location primarily in catheter interventions because life-threatening complications like pneumothorax have not been observed in this location, hemorrhages can be controlled more easily, access is easier, and the intervention does not obstruct cardiopulmonary resuscitation, although hematoma, arterial puncture, and thrombosis complications have been encountered frequently . While jugular areas also have been preferred to a great extent because of less complication development, and easier control of hemorrhages, possible anatomical variations may cause failure. In our department, subclavian vein in children with less weight, jugular vein in children with higher weight, and femoral vein in children with hemorrhage disorder have been preferred.
The literature reports 1-42% of complications based on the intervention in catheter insertions [10,11]. In our study, the complication rate during CVC intervention was 33,3 (29/87). While it was stated that the most frequently encountered complication during the operation has been catheter malposition , in our study, 29,9% of them were arterial puncture and 3,4% were pneumothorax/hemothorax. We infer that, most frequent complications we have encountered have been arterial puncture, because the most freguently utilized intervention was subclavian. We attribute the absence of malposition and arrhythmia to the use of fluoroscopic guidance during the operation. Since fluoroscopy was utilized during the operation, there was no need for a routine chest X-ray after the intervention. Although some authors have stated that there has been no need for a routine chest X-ray unless there is doubt about a complication, they have also remarked that frequent and thorough physical examination is necessary if the chest X-ray has not been taken [13,14].
CVC application is conducted with landmark technique in our department. Frequently encountered intervention complications have been mechanical ones, such as arterial puncture, pneumothorax, arrhythmia, malposition, and air embolism. Rarely reported complications are hemorrhage due to traumatization of main veins, airway injury, medulla spinalis trauma, chylothorax, pleural effusion, cardiac tamponade, catheter rupture, stay of the guide wire in the vein, development of fistule, hydrothorax, hemothorax, embolization of the ruptured catheter piece in the lungs, nerve damage, thrombosis in the vein where catheter is inserted, and hematoma in the intervention area . Arterial puncture has been our most frequently encountered complication with 29,9%. This value is higher compared to the literature. Literature states the frequency of pneumothorax between 1,2% and 6% [5,9]. Our second most frequent complication has been pneumothorax with a rate of 3,4%, and it has been encountered only on subclavian catheters. Ergül et al. have established that serious complications have emerged in the subclavian area, and that femoral and jugular locations have been safer for pediatric patients . In our study, among catheterization locations with regard to the existence of operational complications, they were encountered more frequently in the right jugular and left subclavian areas.
Ultrasonography-guided catheterization decreases all interventive complications, including pneumothorax [15,16]. Positioning of the catheter tip in the right atrium is the most frequent malposition. In CVC applications, catheter tip should be positioned right above the point of junction between right atrium and superior vena cava. Because of choosing wrong sized catheter for the patient, and forging more than needed, the catheter may reach the right atrium. The most effective method in detecting malposition is the utilizaton of bedside ultrasonography for viewing that the catheter is in the point of junction between vena cava superior and the right atrium . Another method for preventing these kinds of complications is the placement of catheter with fluoroscopic guidance, as utilized in our study. Since the movements of the wire and the catheter can be monitored, improper placement of the catheter is out of the question .
Complications encountered during monitorisation were evaluated under subtopics as “infection”, “thrombosis”, and “other”. The most frequent complications during monitorisation were catheter-related bloodstream infections. Although one might think that infections are more probable in the femoral area, because this area carries a higher risk of urine and feces contamination; recent studies have stated that there has been no significant difference between subclavian and jugular areas with regard to catheter infections. Likewise, no significant differences between these areas were established in our study as well. Catheter-related bloodstream infections in central venous catheters without tunnel change according to the catheter location, period of catheterization, and the lumen number of the catheter. Infection risk increases in catheters with more than one lumen . Ergül et al. have stated that the infection rate increases as the catheterization period is elongated. They indicate that utilization of central catheter cloths with chlorhexidine does not decrease the rate of infection; and that they are not suggested unless all other measures are taken but the catheter infection has not been eliminated .
Chung et al. have stated in their review that the risk of thrombosis may account for 0-50%; and they have accentuated that catheter type, catheter size, and the underlying disease play a role in the development of thrombosis. According to the literature, there is a higher probability of thrombosis in femoral vein compared to other locations. In femoral catheterizations lasting more than 5 days, utilizing ultrasonographic monitoring for thrombosis twice a week is an effective method for detecting thrombosis. Clinically asymptomatic thrombosis rates are higher than symptomatic ones [13,20]. No thrombosis was monitored among our patients.
Karapinar and Cura have evaluated the accidental extraction of the catheter as monitorization complication and reported its rate as 3,3% . Among our cases, the rate of accidental extraction of the catheter was established with a significantly higher rate than in the literature as 15,5%. However, as in many studies, extraction and occlusion of the catheter were not defined as complications in our study as well.
Central venous catheterization application is technically difficult in pediatric patients; various complications may be encountered during intervention and monitorisation. Increased experience of the physician and maintenance of proper conditions decrease the rate of catheter-related complications. Since more serious complications have been encountered in subclavian areas compared to femoral and jugular areas, primary choice should be femoral and jugular areas. We consider that utilization of fluoroscopy during operation decreases the rate of complications like malposition and arrhythmia.
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Nevin Aydın, Osman Esen, Gülseren Yılmaz. Effect of fluoroscopy in central vein catheterization in children. Ann Clin Anal Med 2022;13(Suppl 1): S1-5
Comparison of video laryngoscopy and direct laryngoscopy for inexperienced pediatric residents
Yılmaz Seçilmiş, Seda Gümüştekin
Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
DOI: 10.4328/ACAM.21043 Received: 2022-01-05 Accepted: 2022-02-09 Published Online: 2022-03-13 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S6-10
Corresponding Author: Yılmaz Seçilmiş, Department of Pediatric, Faculty of Medicine, Erciyes University, 38039, Kayseri, Turkey. E-mail: firstname.lastname@example.org P: +90 506 301 31 74 F: +90 352 437 58 25 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2195-3551
Aim: Recent advances in video technology and fiber optic systems have resulted in the development of new intubation tools and technologies such as video laryngoscopes. It has been shown that as the number of endotracheal intubation attempts with conventional laryngoscopy increases, complications also increase. The aim of this study was to determine the factors affecting the successful use of video laryngoscopy on a child manikin and to compare the success rates of direct laryngoscopy and video laryngoscopy.
Material and Methods: Our study was carried out on a child manikin in the medical skills laboratory. The success rates of direct laryngoscopy, video laryngoscopy and repetitive video laryngoscopy in the hands of experienced and inexperienced, trained and untrained users were compared by comparing the time to visualize the vocal cords and the rates of successful intubation at the first attempt.
Results: A significant difference was found between conventional direct laryngoscopy and video laryngoscopy in terms of glottic view times (p<0.001). While there was no significant difference in the success of direct laryngoscopy between the experienced and inexperienced participant groups, glottic view time was significantly lower in the experienced group (p=0.061, p=0.005, respectively). It was determined that trained participants had a shorter time to see the vocal cords (p=0.015).
Discussion: Since the use of video laryngoscopy after training in inexperienced people significantly reduces the time to see the vocal cords, video laryngoscope should be available and training should be given before use, especially in places where inexperienced pediatricians work intensively.
Keywords: Video Laryngoscopy, Intubation, Airway, Pediatric Emergency
The difficulty of intubation increases in pediatric patients due to the presence of hypertrophic adenoids, tonsils, and narrow airways. For these reasons, difficult airway and intubation complications are more common in children compared to adult patients . Video laryngoscopes are a different laryngoscopy method that allows an indirect vision through an optical system placed at the tip of the blade . While this method allows the operator to view the glottis closely on a monitor screen without aligning the oral, pharyngeal and tracheal axes, it also eliminates the requirement for cricoid pressure and external laryngo-pharyngeal maneuver during intubation with the traditional method . In addition, it allows the recognition of anatomical structures and external laryngeal manipulation, and the correct placement of the endotracheal tube by using the laryngoscopic view shared by an inspector other than the airway manager during intubation . It has been shown that complications increase as the number of classical laryngoscopy and endotracheal intubation attempts increase in difficult airway management . Video laryngoscopy assisted tracheal intubation devices have become an alternative to traditional laryngoscopes in recent times. Video laryngoscopy is preferred as the first approach in patients with difficult airway . It is known that a successful direct laryngoscopy requires education and experience . However, it is quite possible that many airline managers are not fully familiar with the operating mechanics of these devices, as they are not in routine use and are not available at all centres; It is vital to know not only the restrictions imposed by the devices, but also for their use . Due to the differences in years, emergency and intensive care conditions, and airway difficulties in studies conducted to date, a complete comparison between direct and video laryngoscopy use has not been made. In order to provide optimal conditions in an emergency, pre-training and rehearsal are required . The aim of this study was to determine the factors affecting the successful use of video laryngoscopy on a child manikin and to compare the success rates of direct laryngoscopy and video laryngoscopy.
Material and Methods
The study was approved by the local ethics committee (approval number: 2021/561). Resident pediatricians who received 2 years of pediatric training and had 50 or more intubations participated in this study. Experienced airway manager, those who have not completed two years and intubated less than 50 years, was accepted an inexperienced airway manager. Pre-intubation video laryngoscopy training was given to the participants who volunteered for the training by a pediatric emergency specialist.
Our study was carried out on a child model in the medical skills laboratory of our institution. The model is a pediatric intubation trainer (255-00001)® (Photo). The size of the model is compatible with a 6-year-old patient. Thus, equal intubation difficulty was provided for all participants in the study. All intubations were performed with a 5 mm cuffed endotracheal tube (ETT). The cuff was inflated with a 5 ml syringe. Number two curved blades were used in the study. The study was carried out in five separate sessions. First, participants were intubated with conventional direct laryngoscopy. Success rates and vocal cord visualization times were recorded. Then, intubation was performed with video laryngoscopy. Correct placement of the endotracheal tube by the participants was considered successful intubation, and correct positioning was confirmed by inflating the model’s lungs with the aid of a balloon valve mask. Finally, video laryngoscopy was performed again.
Participants were divided into groups as those who received video laryngoscopy training and did not, and those who were experienced and those who were not. The success rates of direct laryngoscopy, video-laryngoscopy, and repeated video- laryngoscopy in experienced and inexperienced, trained and untrained users were compared by comparing vocal cord visualization times and successful intubation rates at the first attempt.
Statistical analysis was performed using IBM SPSS Statistics for Windows software (version 22.0; IBM Corp. Armonk, NY, USA). The Shapiro–Wilk test was used to assess the normality of the parametric data. Descriptive statistics are given as number and median (25th–75th percentile). The Chi-Square test was used to compare categorical variables. The Wilcoxon test was used to compare two paired groups, and the Friedman test was used to compare more than two paired groups. The Mann–Whitney U test was used to compare non-normally distributed groups. A p-value < 0.05 was considered statistically significant.
A total of 67 participants were included in the study. Thirty-three (49.3%) of the participants were experienced in intubation and 34 (50.7%) were inexperienced. A total of 201 intubations were performed. A significant difference was found between conventional direct laryngoscopy and video laryngoscopy in terms of vocal cord visualization times (p<0.001). Similarly, a significant difference was found between video laryngoscopy and repeated video laryngoscopy in terms of vocal cord visualization times (p<0.001).
While 30 (90.9%) of the experienced participants were successful in conventional direct laryngoscopy, the remaining 3 (9.1%) were evaluated as unsuccessful. In inexperienced participants, these rates were 25 (73.5%) and 9 (26.5%), respectively. While there was no significant difference in the success of direct laryngoscopy between the experienced and inexperienced participant groups, vocal cord visualization time was significantly lower in the experienced group (p=0.061, p=0.005, respectively) (Figure 1). Table 1 shows the effect of the experience factor on laryngoscopy success.
There were 40 (59.7%) participants who received video laryngoscopy training and 27 (40.3%) who did not. There was no difference in success rates between those who received video laryngoscopy training and those who did not. However, it was determined that the participants who received the training had a shorter time to see the vocal cords (p=0.015) (Table 2) (Figure 2).
In repeated video laryngoscopy attempts, it was seen that the technical or personal characteristics of the participants did not affect the application, and all participants saw the vocal cords at similar average times, all participants were successful when they performed video laryngoscopy for the second time (Figure 3). After repeated trials, all participants were able to successfully use the provided video laryngoscopes.
Video laryngoscopy can be considered a more successful application than traditional video laryngoscopy, especially when training is provided for pediatric residents who will work in the practice of pediatric intubation, or when the participant gains experience. Ozawa et al. in a study by 27 experienced neotologists, it was shown that the use of video laryngoscopy increased the laryngoscopy easiness score . We found that pre-intubation training did not affect the success rate of intubation, but reduced the time to visualization of the vocal cords. In light of these data, video laryngoscopy method, which is applied with training instead of traditional direct laryngoscopy, seems to be more suitable for intubation in pediatric cases. At the same time, in the study conducted by Adil Omar et al. with 100 inexperienced medical assistant students, it was reported that a higher number of successful intubations, and shorter intubation times were achieved with video laryngoscopy compared to the traditional method . When evaluated according to the previous experience of the participants, it was seen that experienced and inexperienced participants in pediatric intubation did not differ in terms of intubation success rates, but experienced participants visualized the vocal cords faster. When video laryngoscopy was performed for the first time and again, it was not significant whether there was previous intubation experience or not. People who received video laryngoscopy training, had shorter video intubation time, but when the second application was performed, those who did not receive training achieved the same success rate as those who received training.
In comparative studies performed with C-Mac laryngoscope and direct laryngoscopy, it has been reported that C-Mac is more successful in both normal and difficult airway management compared to direct laryngoscopy [12-14]. In a retrospective study by Sakles et al., it was shown that video laryngoscopy in the emergency department led to a higher success rate and fewer esophageal complications . Similarly, in our study, when inexperienced participants were given video laryngoscope experience, a very high success rate was achieved, while all participants achieved successful intubation during repeated attempts.
In the retrospective study by Matthew et al. in 2016, covering a 10-year period in the pediatric emergency, 452 patients were included, and approximately half of the patients who underwent video laryngoscopy and direct laryngoscopy were compared, and they found no significant difference between direct laryngoscopy and video laryngoscopy in terms of intubation success and complications . The reason for this finding was that the opening of the oral cavity decreased during intubation using a video laryngoscope, and the operable cavity of the oropharynx was also narrowed, and the angle adjustment of the catheter in the oropharyngeal cavity became more difficult.
In some studies on the adult emergency, it has been shown that the rate of successful intubation at the first attempt increased when video laryngoscopy is used compared with direct laryngoscopy [17,18]. In our study, similar to the results of Matthew et al.’s study, there was no significant difference between video and direct laryngoscopy at first intubation attempts, but when the participants gained experience, it was seen that a hundred percent success rate was achieved with video laryngoscopy.
Szarpak et al. compared the efficiency of endotracheal intubation between the Macintosh and the Intu Brite video laryngoscope with inexperienced participants, the superiority of the video laryngoscope was not demonstrated. However, the success of the first intubation was found to be higher in the Macintosh . Hendrick et al. in a study conducted on inexperienced participants, it was shown that video laryngoscopy gave better results in difficult airway stimulation. In the study of Malik et al. with experienced anesthesiologists, when the success rate of traditional laryngoscopy with three different video laryngoscopes was compared, the overall success rate of video laryngoscopy methods was 96.7%, the traditional success rate was 90% [14,20]. In a study conducted on 360 patients in China, it was reported that there was no difference in the use of video laryngoscopy in airway management that is not difficult . In our study, the visual time of the vocal cords decreased significantly in video laryngoscopy with repeated experience, and all participants had a successful repeat attempt. The success of all participants in the second video laryngoscopy trial indicates that the success of the application can be quite high after gaining experience in video laryngoscopy.
In a national survey conducted in England, in public hospitals, while video laryngoscopy is common in 91% of anesthesia departments and 50% in intensive care units, the rate of use of video laryngoscopy in pediatrics and emergency departments in private hospitals is very low . In 2015, the Difficult Airway Society (DAS) recommended in the difficult intubation guide that video laryngoscopy training should be given and available in all intubated areas . In our study, we found that the duration of visualization of the vocal cords decreased significantly after training in inexperienced pediatric residents. According to these data, video laryngoscopy should be available and its use should increase in pediatric hospitals.
As a result, since the use of video laryngoscopy after training in inexperienced persons significantly reduces the time to see the vocal cords, video laryngoscope should be available and training should be given before use, especially in places where inexperienced pediatricians work intensively.
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3. Jungbauer A, Schumann M, Brunkhorst V, Börgers A, Groeben H. Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. Br J Anaesth. 2009;102(4): 546-50.
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5. Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012;116(3): 629-36.
6. Pacheco GS, Patanwala AE, Mendelson JS, Sakles JC. Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period. Pediatr Emerg Care. 2021;37(12): 1098-103.
7. Soar J, Nolan JP, Böttiger BW, Perkins GD, Lott C, Carli P, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation. 2015;95: 100-47.
8. Berkow LC, Morey TE, Urdaneta F. The Technology of Video Laryngoscopy. Anesth Analg. 2018;126(5): 1527-34.
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10. Ozawa Y, Takahashi S, Miyahara H, Hosoi K, Miura M, Morisaki H, et al. Utilizing Video versus Direct Laryngoscopy to Intubate Simulated Newborns while Contained within the Incubator: A Randomized Crossover Study. Am J Perinatol. 2020;37(5): 519-24.
11. Bahathiq AO, Abdelmontaleb TH, Newigy MK. Learning and performance of endotracheal intubation by paramedical students: Comparison of GlideScope(®) and intubating laryngeal mask airway with direct laryngoscopy in manikins. Indian J Anaesth. 2016;60(5): 337-42.
12. Sakles JC, Mosier JM, Chiu S, Keim SM. Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med. 2012;42(4): 400-5.
13. Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Video laryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev. 2016;11(11): 181-97.
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15. Sakles JC, Mosier JM, Patanwala AE, Arcaris B, Dicken JM. The Utility of the C-MAC as a Direct Laryngoscope for Intubation in the Emergency Department. J Emerg Med. 2016;51(4): 349-57.
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Yılmaz Seçilmiş, Seda Gümüştekin. Comparison of video laryngoscopy and direct laryngoscopy for inexperienced pediatric residents. Ann Clin Anal Med 2022;13(Suppl 1): S6-10
Investigation of the effect of lacosamide on renal function: A 5-Year retrospective cohort study
Department of Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey
DOI: 10.4328/ACAM.21059 Received: 2022-01-14 Accepted: 2022-02-18 Published Online: 2022-03-01 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S11-15
Corresponding Author: Ahmet Adıguzel, Department of Neurology, Faculty of Medicine, Inonu University, Malatya, Turkey. E-mail: email@example.com P: +90 422 342 06 60 Corresponding Author ORCID ID: https://orcid.org/0000-0001-5197-7063
Aim: Lacosamide, a third-generation antiepileptic drug, is used as adjunctive treatment of partial-onset seizures. It is mainly eliminated through the kidneys. The drug acts by enhancing the slow inactivation of voltage-gated sodium channels. The aim of this study was to investigate the long-term effects of lacosamide on renal function.
Material and Methods: The study included two groups of patients with epilepsy (those treated and those not treated with lacosamide) and a healthy control group. Plasma creatinine, blood urea nitrogen, glomerular filtration rate (GFR; by the Modification of Diet in Renal Disease formula), and sodium levels were calculated for the participants at four retrospective time points over 6 years (t0-t1-t2-t3).
Results: A total of 123 (female/male=58/65) participants, with a mean age of 33.9±9.5 years, were included in the study. The study covered a total period of 57.7±5.5 months. GFRs calculated at all time points for the group receiving lacosamide (GFR0:123.1 mL/min/1.73m2, GFR1:115.1 mL/min/1.73m2, GFR2:112.9 mL/min/1.73m2, and GFR3:102.3 mL/min/1.73m2) were lower than those of the healthy control group (p<0.05). GFR 3 levels was calculated to be lower in patients treated with lacosamide than in patients not treated with lacosamide (p<0.05).On performing statistical analysis, higher plasma Cr0.2.3 levels were found for the group using lacosamide compared to the healthy control group (p<0.05).
Discussion: In this study, all parameters evaluated to investigate the effect of lacosamide on renal functions were found to be within normal ranges in each group. However, plasma GFR levels were found to be lower in the group using lacosamide compared to the control group.
Keywords: Lacosamide, Antiepileptic Drugs, GFR, Sodium Channel Blocker, Seizure
Epilepsy treatment usually begins as monotherapy. However, in case of uncontrolled seizures, adjunctive drugs are added to the therapy. In 30%–40% of patients with epilepsy, seizures cannot be fully controlled despite the administration of antiepileptic drug (AED) polytherapy . Lacosamide, a third-generation AED, can be administered to patients who still have uncontrolled seizures despite the use of at least two AEDs. Lacosamide was approved by the U.S. Food and Drug Administration (FDA) in 2008 as an adjunctive therapy for patients with partial-onset epilepsy aged ≥17 . When administered adjunctively at a dose of 200–600 mg/day in the treatment of motor and non-motor focal seizures, with or without awareness, lacosamide can significantly reduce the frequency of seizures due to the fast onset of its anticonvulsant effect . It has a well-known pharmacokinetic profile . Oral lacosamide has a bioavailability of approximately 100% and reaches peak plasma concentration in 1–4 h . Lacosamide is eliminated from the systemic circulation mainly by the excretory system and biotransformation. Dose adjustment is not required for lacosamide in adult and pediatric patients with a glomerular filtration rate (GFR) of >30 mL/min/1.73m2 . Lacosamide has a more favorable side-effect profile than some older AEDs, with dizziness, headaches, and nausea as the most common side effects . Antiepileptic drugs are usually used for an extended period of time or for life. Some side effects or metabolic changes may occur years later. This study investigated the effect of lacosamide on renal functions over a period of approximately 5 years. GFR, used in the diagnosis, follow-up, and evaluation of renal diseases, is considered the best indicator of renal function . The Modification of Diet in Renal Disease (MDRD) formula was used to calculate GFR . The study included three groups: one group using at least two AEDs + lacosamide, one group using at least two AEDs, and another group composed of healthy individuals. The groups were compared in terms of changes in serum GFR and creatinine (Cr) levels at time points t0, t1, t2, and t3. Our study aimed to show the long-term effects of lacosamide on renal function. Our hypothesis was that GFR would tend to decrease further over time in the group using lacosamide.
Material and Methods
This research was designed as a retrospective cohort study. The study enrolled patients who were regularly monitored at the epilepsy outpatient clinic of a tertiary health-care center. The study was approved by the ethics committee (on 14.12.2021, decision number: 2021/2847) and performed in accordance with the criteria of the Helsinki Declaration. Informed consent forms were obtained from the participants.
In this study, patients were divided into three groups. The first group included patients with epilepsy who received at least two AEDs along with lacosamide. The second group comprised patients with epilepsy who received at least two AEDs other than lacosamide. Finally, the study also included a control group consisting of healthy individuals who did not use any AED. Clinical information and laboratory parameters were screened using electronic files of patients followed up for epilepsy between 01.01.2013 and 01.12.2021. Those who were included in the healthy control group were randomly selected amongst individuals who had at least four records over a 6-year period in the electronic database. Epilepsy diagnosis was confirmed based on the International League Against Epilepsy 2014 guideline . Inclusion criteria were as follows: a confirmed diagnosis of epilepsy, age over 18 years, using at least two AEDs, and having lacosamide therapy initiated at our center. The exclusion criteria were as follows: failure to use AEDs regularly, consistently taking medications due to a chronic disease other than epilepsy, less than one follow-up per year as per outpatient clinic records, a history of acute or chronic renal failure, and having undergone epilepsy surgery. Patients who were found to use lacosamide for a short period of time (<4 years), those who were switched to a lower AED dose, or those who stopped using AED were rejected from the study. The number of patients was determined as follows: G-Power analysis was used; GFR of 102±17 mL/min/1.73m2 for the patient group and GFR of 119±24 mL/min/1.73m2 for the control group. Accordingly, with an effect size of 0.817, α of 0.05, and 1-β error probability of 0.95, it was found that a minimum of 40 patients must be included in the study.
Venous blood samples were collected in ethylenediaminetetraacetic acid-containing tubes after a 12-h fasting duration to evaluate the laboratory parameters of the patients and control group. The blood samples were analyzed using Beckman Coulter® AU 5800. Participants’ serum Cr levels were recorded. GFR was calculated according to the following MDRD formula: 175 × [(Serum Cr) − 1.154] × [(Age) − 0.203] × (0.742 if female) × (1,212 if African American) . In this formula, the GFR unit is mL/min/1.73 m2, and all GFR results in the study are presented accordingly. The parameters obtained were evaluated at four time points. Time point t0 indicates the week when lacosamide was initiated for the first group, and at least 49 months back for the other groups. t1, t2, and t3 indicate the period between 18–30 months, 31–48 months, and 49–72 months, respectively. Laboratory data pertaining to the three groups were categorized in accordance with these time points. The parameters mentioned in the article are tagged using the same system (e.g., GFR1, Cr3)
The data obtained at the end of the data collection phase were transferred to a computer for analyses. SPSS® 26.0 (SPSS Inc., Chicago, IL, USA) software suite was used for statistical analysis. Numerical data are presented as arithmetic mean, standard deviation, and minimum and maximum values, and categorical data are presented as frequency distributions and percentages. Means were compared among the groups, and analysis of variance and Eta coefficient test were used for evaluating daily doses of AED, age, and t, t2, and t3 periods. Multivariate Post Hoc analysis was performed to compare laboratory results among the groups. The Chi-square test was used to compare categorical data (gender and frequency of use of AED types across groups). Statistical significance was set at p <0.05.
The study included 44 (35.8%) patients with epilepsy using at least two AEDs + lacosamide, 43 (35.0%) patients who used AEDs other than lacosamide, and 36 (29.2%) healthy individuals. There were 58 (47.2%) females and 65 males (52.8%). Participants had a mean age of 33.9 years. For all the three groups, the first parameter evaluated for the first study was recorded as t 0 time. Average time periods for the groups were as follows: t 1 = 23.1 months, t 2 = 38.2 months, and t 3 = 57.7 months. There was no significant difference between the groups in terms of t 1 , t 2 , and t 3 . A strong correlation was observed between the groups in terms of age; gender distribution; and t 0 , t 1 , t 2 , and t 3 time points in which the parameters were studied (Table1). For patients with epilepsy using lacosamide and those not using it, doses of other AEDs and frequency of use were investigated. The current mean dose of lacosamide was analyzed as 298±100 mg/day. There was no significant difference between the two groups in terms of frequency of use and daily doses of valproic acid, levetiracetam, carbamazepine, clobazam, lamotrigine, zonisamide, and topiramate (p>0.05) (Table 2). Among these three groups, the results of renal functions (Cr, GFR) were evaluated using multivariate Post Hoc analysis (Table 3). In those using lacosamide, plasma Cr levels were t 0 : 0.70 mg/dL, t 1 : 0.69 mg/dL, t 2 : 0.76 mg/dL, and t 3 : 0.88 mg/dL. In individuals with epilepsy who did not use lacosamide, plasma Cr 0.1.2.3 levels were t 0 : 0.65 mg/dL, t 1 : 0,65 mg/dL, t 2 : 0.68 mg/dL, and t 3 : 0.75 mg/dL. On performing statistical analysis, higher plasma Cr 0.2.3 levels were found for the group using lacosamide compared to the healthy control group (p < 0.05). Additionally, plasma Cr 3 levels were found to be higher for the group using lacosamide as compared to the group using other AEDs (p<0.05). GFR results calculated according to the MDRD formula for the three groups, the principal result investigated in the study, were also
compared. Between groups that used lacosamide GFR 3 : 102.3 mL/min/1.73m 2 and not used GFR 3 : 115.9 mL/min/1.73m 2 (p<0.05). When GFR measurements were compared between the group using lacosamide and the control group, GFR was shown to be high in the control group for all four measurements (GFR 0.1.2.3 ) (p<0.05). There was no significant difference between the group that did not use lacosamide and the control group in terms of GFR 0.1.2.3 results (p>0.05).
Lacosamide is a third-generation AED used as adjunctive therapy for partial-onset seizures in most countries. It was licensed in Turkey in 2012. In Turkey, its prescription is contingent on at least 6 months of combined use of two AEDs; hence, it is usually preferred as the third or fourth AED in drug-resistant epilepsy cases. . Lacosamide is an amino acid (chemical formula: acetamido-N-benzyl-3-methoxypropionamide), and unlike other sodium channel blockers, it acts by selectively enhancing the slow inactivation of voltage-gated sodium channels. Thus, it results in a decrease in the pathological hyperexcitability of neurons without altering their physiological activity . As a functionalized amino acid compound with linear pharmacokinetics, lacosamide has 100% oral absorption in adults and demonstrates a low plasma protein binding of <15%. It has a half-life of 13 h and reaches peak blood concentration within 1–2 h. It is mainly excreted via the kidneys and has no known drug-drug interaction . Clinical studies have shown that lacosamide does not affect plasma levels of carbamazepine, valproic acid, lamotrigine, levetiracetam, oxcarbazepine, and phenytoin to a certain extent . This property of lacosamide has contributed to the reliability of our work. In other words, renal function and electrolytes of the group using lacosamide were minimally affected by other AEDs. In this study, the inclusion of a control group composed of healthy individuals enabled performing comparisons between the group using lacosamide and other AEDs and the control group.
Our study found strong correlations between the distribution of gender and mean age among the three groups. This result suggests that age and gender-related variables would have a minimal effect on the parameters analyzed in this study. In addition, there was no significant difference between the time points (t0, t1, t2, and t3) used in this study.
Studies showed that factors such as renal function, gestational status, age, and critical diseases may affect the pharmacokinetics of lacosamide. Indeed, our main goal in this study was to analyze the effect of lacosamide on renal functions. The normal range of GFR is 120±25 mL/min/1.73m2 for men and 95 ± 20 mL/min/1.73m2 for women . It has been reported that there is currently no need to monitor renal functions when lacosamide is used . Other studies have suggested that dose adjustment is not required for lacosamide in adult and pediatric patients with GFR of > 30mL/min/1.73m2 .
In our study, we evaluated long-term effects of lacosamide on GFR among the study groups. We compared the GFR results of the group using lacosamide and the healthy control group. Although the GFR values of the groups were within normal limits, we have achieved a very assertive result. GFR results measured at all time points (GFR0.1.2.3) were found to be lower in those who used lacosamide compared to the healthy control group (p < 0.05). There was no clear difference between patients with epilepsy receiving AEDs other than lacosamide and the healthy control group. Between these two groups, only GFR3 results were low in the group of patients with epilepsy who did not use lacosamide. The healthy control group had GFR3: 120.6 mL/min/1.73m2, whereas the group receiving AEDs other than lacosamide had GFR3: 115.9 mL/min/1.73m2 (p < 0.05). Based on this result, we tend to think that other AEDs also result in lower GFRs after a certain period of time. However, this hypothesis should be backed up with clearer evidence. We compared patients with epilepsy among themselves based on the GFR result. The group that received lacosamide as part of its therapy had lower GFR3 (102 mL/min/1.73m2) compared to the group that did not receive it (115.9 mL/min/1.73m2) (p < 0.05). The data in the study covers a period of average 57.7 ± 5.5 months. During the follow-up period of approximately 5 years, the GFR level remained within the normal range in all three groups. However, GFR results were found to be lower in the group using lacosamide compared to the other two groups. A 2013 study involving healthy volunteers and patient groups investigated the effects of lacosamide on renal functions and its correlation with plasma drug concentrations. Accordingly, it was found that in those with decreased renal function, drug clearance was also reduced, and as a result, the plasma concentration of lacosamide increased. The same study advised reducing the drug dose in those with renal dysfunction . Current publications discuss plasma concentrations of the drug or the use of follow-ups with renal function tests in those who use lacosamide. A paper published in 2020 stated that renally excreted drugs such as lacosamide can accumulate in the body and cause toxicity with a decrease in renal function . That study emphasized that therapeutic drug monitoring (TDM) could help prevent a drug from reaching toxic concentrations . However, no advice has been given as to when TDM should start or how frequently it should be performed for lacosamide. Another study published in 2021 emphasized that TDM should be performed for lacosamide in those with severe renal dysfunction, and its dose should be calculated based on renal function . This can prevent the drug from causing side effects associated with high plasma concentrations. Based on these current studies, we can recommend monitoring the plasma concentration of lacosamide in those with moderate-to-severe renal dysfunction. In our study, no renal dysfunction was detected in any of the participants. Accordingly, we can contend that the risk of developing any renal dysfunction is very low in patients with epilepsy receiving lacosamide + at least two AEDs over a period of approximately 5 years.
This study has some limitations. First, not every patient was treated with an equal dose of lacosamide. Second, the AEDs used by the two groups other than lacosamide were not the same. Finally, it is not known whether participants used any drug for a short period of time (e.g., painkillers, flu medications, and antibiotics) during the period when their blood was analyzed in the laboratory.
In this study, we investigated the effects of lacosamide, one of the latest AEDs used in Turkey, on renal functions. For about 5 years, it was observed that lacosamide did not reduce GFR below the normal range. However, GFRs were found to be lower in those who received lacosamide at all time points compared to the control group. There are few studies in the literature investigating the long-term effects of lacosamide on renal functions. Therefore, more comprehensive and long-term cohort studies are needed.
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19. Kalaria SN, Armahizer M, McCarthy P, Badjatia N, Gobburu JV, Gopalakrishnan M. A prospective, real-world, clinical pharmacokinetic study to inform lacosamide dosing in critically ill patients undergoing continuous venovenous haemofiltration (PADRE-02). Br J Clin Pharmacol. 2021;87(11):4375-85
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Ahmet Adıguzel. Investigation of the effect of lacosamide on renal function: A 5-Year retrospective cohort study. Ann Clin Anal Med 2022;13(Suppl 1): S11-15
Our tracheostomy results in the intensive care unit, outcomes of 199 patients
Erdinç Koca 1, Çiğdem Fırat Koca 2
1 Departmant of Anesthesiology and Reanimation, Malatya Training and Research Hospital, 2 Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Malatya Turgut Özal University, Malatya, Turkey
DOI: 10.4328/ACAM.21076 Received: 2022-01-22 Accepted: 2022-03-04 Published Online: 2022-03-05 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S16-20
Corresponding Author: Çiğdem Fırat Koca, Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Malatya Turgut Özal University, Malatya, Turkey. E-mail: firstname.lastname@example.org P: +90 530 223 96 24 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8990-0651
Aim: The history of tracheostomy goes back to 3600 BC. Percutaneous dilatational tracheostomy was described in 1985 by Ciaglia. Percutaneous dilatational tracheostomy is quick, less traumatic, and has fewer complications. The aim of our study was to analyze the tracheostomy results of 199 patients in our Intensive Care Units.
Material and Methods: We included patients who underwent tracheostomy in our Intensive Care Units between January 2014 and December 2018 in Malatya Training and Research Hospital. A retrospective analysis was carried out for diagnosis, complications, surgical tracheostomy requirement reasons, demographics, comorbidity, ICU stay period, date of tracheostomy procedure, days to tracheostomy procedure from day of admission to ICU, days to tracheostomy procedure from initial tracheal intubation, days connected to mechanical ventilation, tracheostomy technique, urgent or elective, the final state of the patients were analyzed. Data were collected from the patients’ records. The data of the study was evaluated through SPSS ‘statistical package for social sciences’ (spss17.0) ‘program.
Results: The average age of discharged patients was 56.3 years and 74.4 for the dead patient group. There was a statistically significant increase between age and mortality, and between Apache II score and mortality (p< 0.05).
Discussion: According to our study results, percutaneous tracheostomy is a method with a low complication rate and easy applicability. No statistically significant results were found between the time from admission to the intensive care unit to the day of tracheostomy opening, the time to stay intubated, and mortality.
Keywords: Percutaneous, Tracheostomy, Intensive Care Units
Tracheostomy is a quite ancient surgical intervention, its history dates back to 3600 BC on Egyptian tablets. Chevalier Jackson described a surgical method for tracheostomy in 1932 [1)]. Ciaglia introduced the percutaneous dilatational tracheostomy (PCT) method developed over a guidewire in 1985 .
The tracheostomy procedure has some advantages, including enhancement of patient endurance, lessening the sedation requirement, protection of the larynx from irritation, improving nursing care, and reduction of dead space. Thanks to these benefits of the procedure, respiratory care and weaning from mechanical ventilatory support may be easier and more comfortable. The choice depends mainly upon the hazards and advantages of tracheostomy procedure versus prolonged intubation and the approval of the patient’s relatives and clinical condition. There is no consensus on the accurate time for the tracheostomy procedure .
Thanks to the progress and developments in the treatment modalities for critically ill patients; prolonged mechanical ventilation and tracheostomy numbers have been increased . The timing of the tracheostomy procedure remains unclear . It can differ for each patient and according to the pathology . Percutaneous tracheostomy is a fast, safe, simple procedure and has lower morbidity than surgical tracheostomy procedure [4,6,7].
The aim of our study was to analyze the tracheostomy results of 199 patients in our Intensive Care Units (ICU). We reported the diagnosis, complications, surgical tracheostomy requirement reasons, demographics, comorbidity, ICU stay period, the date of tracheostomy procedure, days to tracheostomy procedure from day of admission to ICU, days to tracheostomy procedure from initial tracheal intubation, the days connected to mechanical ventilation, tracheostomy technique, urgent or elective, the final state of the patient (died, discharged), which clinic the patient was admitted to ICU, APACHE II score.
Material and Methods
a. Study design
The study was created in the Intensive Care Unit of Malatya Training and Research Hospital. We started the study after the approval of the ethics committee of Malatya Clinical Research (ethical approval number: 2019/207). A retrospective analysis was carried out for 199 patients who experienced tracheostomy in our Intensive Care Unit between January 2014 and December 2018 in Malatya Training and Research Hospital. Data were obtained from the patients’ records.
Data included diagnosis, complications, surgical tracheostomy requirement reasons, demographics, comorbidity, ICU stay period, the date of tracheostomy procedure, days to tracheostomy procedure from day of admission to ICU, days to tracheostomy procedure from initial tracheal intubation, days connected to mechanical ventilation, tracheostomy technique, urgent or elective, the final state of the patient (died, discharged), which clinic the patient was admitted to ICU, APACHE II score. One hundred ninety-nine patients who experienced tracheostomy procedures for prolonged intubation for mechanical ventilation were included in our study. The tracheostomy requirement was decided by the resident critical care doctor. Tracheostomy was performed after obtaining informed consent from the first-degree relatives of the patient. The majority of the procedures were carried out at the bedside by resident critical care doctor. The complicated ones (enlarged thyroid gland, coagulopathy, cervical mass etc.) were consulted to ear, nose, throat specialities. These difficult cases were performed by ear, nose and throat doctors in the operating room. The percutaneous tracheostomy technique was used in 184 patients and 15 patients experienced classical surgical procedures.
It was understood from the data that the Griggs technique was used for percutaneous tracheostomy. Percutaneous tracheostomy was performed as a bedside method in the ICU based on a standard protocol. The complicated ones (enlarged thyroid gland, coagulopathy, cervical mass) were consulted to ear, nose, throat specialities. These difficult cases were performed by ear, nose and throat doctors in the operating room and under the close control of an experienced critical care physician using the classic open surgical technique (ST).
The data of the study were evaluated through the SPSS ‘statistical package for social sciences’ (spss17.0)’program. The average standard deviation value was calculated as a percentage.
Binary logistic regression analysis was used to determine risk factors as a probability by obtaining the effects of explanatory variables. Mortality and life status were defined as dependent variables. Age, gender, apache II score, duration of tracheal intubation from ICU admission to tracheostomy date, the tracheal intubation duration to tracheostomy were determined as independent factors. Since the variables were not suitable for normal distribution, the Mann-Whitney U test was used for non-parametric test statistics. In statistical comparisons, alpha error level was accepted as p <0.05.
A total of 199 patients underwent tracheostomy. The demographic data were demonstrated in Table 1. Pathologies for admission to the ICU includes ischaemic cerebrovascular disease, hemorrhage cerebrovascular disease, chronic obstructive pulmonary disease and pneumonia, congestive heart failure, hypertension, coronary artery disease, acute renal failure, multitrauma, amyotrophic lateral sclerosis, Guillain barre, cerebral palsy, gastric cancer, lung cancer, cerebral tumors, pulmonary thromboembolism, chronic renal failure, intracerebral aneurysm, Alzheimer. The most common diagnosis was chronic obstructive pulmonary disease in combination with pneumonia in 74 patients (37 %). The reasons for tracheostomy included prolonged intubation for mechanical ventilation in 153 patients (77 %), failure to separate from mechanical ventilation in 29 patients (14.5) and for maintaining easier secretion cleaning in 17 patients (8.5 %) (Table 2). Elective tracheostomy was performed in 182 patients and 17 patients underwent urgent tracheostomy procedure. The mean age was 73 years (range between 19-100 years); 107 patients were male (53.8 %) and 92 patients were women (46.2 %). The average duration of tracheal intubation from ICU admission to tracheostomy was 23 days (range between 1-60 days). The average tracheal intubation duration to tracheostomy was 21 days (range between 1- 60 days). The mean length of stay in the ICU was 64 days (range between 11- 340 days); 184 patients (92.5 %) underwent PCT in ICU, 15 (7.5 %) patients experienced surgical tracheostomy in operating room. Patients required mechanical ventilation for an average of 62 days (range 10–330 days). The
average APACHE II score was 23. Some patients were extubated and re-intubated before the tracheostomy during the ICU stay. The majority of patients, 136 (68.4 %), were transferred from the emergency department of our hospital to ICU. Internal medicine intensive care unit was following the emergency department with 23 patients (11.6%).
In total, perioperative complications were observed in 6 patients (3 %). Bleeding was observed in 3 patients, none of which was major and easily overcome. Tracheoesophageal fistula was developed in one patient, emphysema occured in one patient and decannulation in one patient. None of these patients died due to these complications. The complications are shown in Table 2.
In 15 patients, the otorhinolaryngologist performed a classical surgical tracheostomy in the operating. The indications for surgical procedure were cervical mass, cervical fixation, coagulopathy, short cervical structure, cervical instability, tracheal stenosis. One hundred seventy-nine patients (89.9 %) died during the ICU stay; 20 patients were transferred to the clinics related to their diagnosis. The relationship between age and mortality, Apache II score and mortality, duration of tracheal intubation from ICU admission to tracheostomy date and mortality, age and mortality, the tracheal intubation duration to tracheostomy and mortality were analyzed statistically (shown in Table 3). The average age was 56.3 years for discharged patients and 74.4 for dead patient group. There was a statistically significant increase between age and mortality, and between Apache II score and mortality. A one-year increase in age increases the risk of exitus by 1.07 times. The average Apache II score was 23.4 for discharged patients and 29.7 for the dead patient group. Similarly, one-unit increment in Apache II score increases the risk of exitus by 1.1 times (p< 0.05). There was no statistically significance between duration of tracheal intubation from ICU admission to tracheostomy date and mortality, gender and mortality, the tracheal intubation duration to tracheostomy and mortality (p>0.05).
In this study, we analyzed 199 patients who underwent tracheostomy performed in our Intensive Care Unit. The average tracheostomy opening day was 21 days, and the most common reasons for postponing tracheostomy were the refusal of patient relatives, the concurrent coagulation disorders. We analyzed the relationship between the tracheal intubation duration to tracheostomy and mortality. There was a slight increase between the tracheal intubation duration to tracheostomy and mortality rate, but we could not show this increase statistically (p>0.05).
Technological improvements, improved health circumstances, increased number of intensive care units have provided to follow up great numbers of critically ill cases and as a result, an inevitable increase in the number of tracheostomy attempts due to prolonged mechanical ventilation. PCT is a bedside procedure and does not require transportation of the patient to the operating room [8,9]. The time for tracheostomy for ventilated patients still remains unclear .
Early PCT maintains early separation from mechanical ventilation, lower pneumonia and lower mortality rates compared with late PCT [11,12]
Rumbak et al. attributed the high mortality rate of their patients to their high APACHE II scores of 27 and 26 for groups. Similarly, our mortality rate was high (89.9 %) . We think that the mortality rate was high in our study due to comorbidities, high number of elderly patients, and long stay in ICU.
The relationship between age and mortality, Apache II score and mortality, duration of tracheal intubation from ICU admission to tracheostomy date and mortality, gender and mortality, tracheal intubation duration to tracheostomy and mortality were analyzed statistically in this study. The average age was 56.3 years for discharged patients and 74.4 for the dead patient group. There was a statistically significant increase between age and mortality, and between Apache II score and mortality. A one-year increase in age increases the risk of exitus by 1.07 times. The average Apache II score was 23.4 for discharged patients and 29.7 for the dead patient group. Similarly, one-unit increment in Apache II score increases the risk of exitus by 1.1 times (p< 0.05). There was no statistical significance between the duration of tracheal intubation from ICU admission to tracheostomy date and mortality, gender and mortality, tracheal intubation duration to tracheostomy and mortality (p>0.05). The average stay in the ICU was 64 days (range between 11- 340 days) in our study. Diaz- Reganon et al. reported that the mean stay in ICU was 21 days in their 800- patient study . They did not report the diagnosis of their patient. We think that PCT is quick, less traumatic, has fewer complications according to the results of our study. Delaney et al. showed a lower incidence of bleeding and exitus ratio of PCT and better wound healing compared with surgical tracheostomy in their large series . G. Diaz-Reganon et al. reported no exitus directly related to the tracheostomy in their study . Fikkers et al. mentioned their major complication rate as 6 %, including bleeding, pneumothorax, and dilatation of a false tract . Perioperative complications were observed in 6 patients (3 %) in our study group. Bleeding was observed in 3 patients and none of them were major and easily stopped. Two of these patients experienced surgical tracheostomy, the other haa a percutaneous tracheostomy. Tracheoesophageal fistula was developed in one patient, and this patient had experienced surgical tracheostomy. Emphysema occurred in one patient and decannulation in one patient. Emphysema and decannulation were developed in two patients that experienced percutaneous tracheostomy. None of these patients died due to these complications.
Bleeding was reported from 0 % to 20 % in the literature . We observed bleeding complication in our three patients (1.5 %) parallel to the literature. We think that this ratio was low due to the number of experienced physicians ready for the tracheostomy procedure for each patient and our technique.
Minimal tissue disruption, tighty tamponade effects of tracheostomy tube, and adrenaline usage for local anaesthetic to the skin maintain minimal bleeding. Abnormal coagulation values especially affect the bleeding percentage [7,16]. Aberrant arterial anatomy was associated with fatal hemorrhage during the procedure [17,18]. Small incision maintains lower bacterial colonisation and stomal infection . No stomal infection was found in our patients.
Our study has some limitations. Since the number of tracheostomies opened with the surgical method was low, we could not compare with the PCT method. The accurate time for tracheostomy, complications, and other data should be analyzed in large series.
In this study, we observed that PCT can be performed by experienced anesthesiologists in patients hospitalized in the intensive care unit with a safe and low complication rate.
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Conflict of interest
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4. Groves DS, Durbin CG Jr. Tracheostomy in the critically ill: indications, timing and techniques. Curr Opin Critl Care. 2007; 13(1): 90–7.
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6. Freeman BD, Isabella K, Cobb JP. A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients. Crit Care Med. 2001; 29(5): 926–30.
7. Díaz-Regañón G, Miñambres E, Ruiz A, González-Herrera S, Holanda-Peña M, López-Espadas F, et al. Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients. Anaesthesia. 2008; 63(11):1198-203.
8. Antonelli M, Michetti V, Di Palma A, Conti G, Alberto Pennisi M, Arcangeli A, et al. Percutaneous translaryngeal versus surgical tracheostomy: a randomized trial with 1-yr double-blind follow-up. Critical Care Medicine 2005; 33: 1015–20.
9. Warren J, Fromm RE Jr, Orr RA, Rotello L C, Horst H M. American College of Critical Care Medicine. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med. 2004; 32(1): 256–62.
10. Khammas AH, Dawood MR. Timing of Tracheostomy in Intensive Care Unit Patients. Int Arch Otorhinolaryngol. 2018; 22(4): 437-42.
11. Rumbak MJ, Newton M, Truncale T, Schwartz S W, Adams J W, Hazard P B, et al. A prospective, randomized, study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheostomy) in critically ill medical patients. Crit Care Med. 2004; 32(8): 1689–94.
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Erdinç Koca, Çiğdem Fırat Koca. Our tracheostomy results in the intensive care unit, outcomes of 199 patients. Ann Clin Anal Med 2022;13(Suppl 1): S16-20
Evaluation of endoscopy and pathology findings in pediatric patients with chronic dyspeptic complaints
Meryem Keceli Basaran 1, Yilmaz Secilmis 2
1 Department of Pediatrics, Gaziosmanpasa Training and Research Hospital, Istanbul, 2 Department of Pediatrics, Faculty of Medicine, Erciyes University, Kayseri, Turkey
DOI: 10.4328/ACAM.21084 Received: 2022-01-26 Accepted: 2022-03-02 Published Online: 2022-03-08 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S21-25
Corresponding Author: Meryem Keceli Basaran, Department of Pediatric Gastroenterology Hepatology and Nutrition, Gaziosmanpaşa Training and Research Hospital, 34250, Istanbul, Turkey. E-mail: email@example.com P: +90 530 171 72 50 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8362-8618
Aim: Upper gastrointestinal system endoscopy findings serve as a basis for starting treatment based on the cause and severity of dyspepsia. Helicobacter pylori (H. pylori) is becoming prevalent in both pediatric and adult patients. We aim to evaluate and discuss the endoscopy and pathology findings in pediatric patients with chronic dyspeptic complaints.
Material and Methods: This study evaluates the endoscopy and pathology findings of 163 pediatric patients who have undergone upper gastrointestinal system (GIS) endoscopy due to chronic dyspeptic complaints. The patients were assigned to four different groups according to their complaints. The underlying complaints as well as endoscopy and pathology findings were compared. Potential links with H.pylori were also investigated.
Results: A breakdown of complaints at the time of admission suggests that 53 (32%) patients had epigastric pain, 49 (30.2%) postprandial fullness/discomfort, 32 (20.3%) nausea and vomiting, and 29 (17.2%) upper abdominal distension. The most common endoscopy findings were antral hyperemia (42.3%) and antral nodularity (21.4%). Esophagitis was present on endoscopy in 14.1% of the patients with dyspeptic complaints. Antral gastritis and esophagitis were more common in H. Pylori-positive patients. There was no statistically significant relationship between H.Pylori and the presence of alkaline reflux.
Discussion: Antral hyperemia, antral nodularity, and esophagitis are common in endoscopic findings of H. Pylori-positive patients with dyspeptic complaints. Although the relationship between duodenogastric reflux (alkaline reflux) and H.pylori is not known, no link was evident in the present study. The incidence of H.pylori has risen among children, and symptomatic children should receive treatment to prevent chronic complications.
Keywords: Dyspepsia, Endoscopy, Child, Helicobacter, Esophagitis, Gastritis
Symptoms such as upper GIS bloating, epigastric pain, early satiety, nausea, vomiting, and burning are called dyspepsia. They can also present with acute, chronic, or recurrent abdominal pain in pediatric patients. This condition is associated with dyspepsia in some pediatric patients who report nonspecific chronic abdominal pain at the time of admission. Although dyspepsia is prevalent at a high rate of 20% to 30%, only 25% of patients apply to medical institutions. Functional dyspepsia constitutes a significant part of dyspepsia. Today, upper GI endoscopy is widely popular in distinguishing functional and organic dyspepsia both in children and adults. Gastritis, peptic (gastric and duodenal) ulcer, gastroesophageal reflux, duodenogastric reflux (DGR), and esophagitis constitute a significant part of the organic causes. The increasing use of endoscopy for pediatric patients has led to an increase in the diagnosis of peptic ulcer, gastritis, and gastric erosion .
Recent studies in children have displayed that the prevalence of peptic ulcers has risen from 1.8% to 19.5% . Peptic ulcer and gastric erosion have been reported in 10-20% of symptomatic children who underwent upper GI endoscopy . The peptic ulcer is usually associated with H.pylori, corticosteroids or non-steroidal anti-inflammatory (NSAID) drugs, systemic diseases, and nutrition . Moreover, H. pylori are the main factor responsible for chronic gastritis and duodenal ulcer in adults and children . Through various pathophysiological mechanisms, H.pylori causes dyspeptic symptoms without causing inflammation and ulceration in the gastrointestinal tract. An improvement in symptoms due to H.pylori treatment has been observed [6,7].
This study aims to analyze the dyspeptic symptoms with characteristics of endoscopy and pathology findings in pediatric patients, and to discuss the relationship between the presence of H.pylori and these findings.
Material and Methods
This study is a retrospective and observational study. Written informed consent was provided by the families of all participants. Approval from the local ethics committee of Taksim Training and Research Hospital was received on 16.01.2019 (no:2). The study procedure followed the Helsinki Declaration and Good Clinical Practice guidelines.
Selection of the patient population
This study was conducted by analyzing the case records of 163 pediatric patients aged between 7-18 years who applied due to chronic dyspeptic complaints between 2017 and 2018 and underwent upper GIS endoscopy.
Upper GI endoscopy was performed due to dyspeptic complaints for a minimum of six months and complaints about meals either at least once a week or persistently in the last three months. Patients who did not previously undergo endoscopy due to chronic dyspeptic complaints were included in the study. Admission complaints, endoscopy findings, and pathology findings were then analyzed.
Patients who had undergone endoscopy, treatment for H.pylori in the last three months, gastrointestinal system surgery, underlying hematological diseases, diabetes mellitus, thyroid disease, congenital heart disease, and received antacid therapy were left out.
Endoscopy procedures of the patients were performed using the EG530WR Endoscopy (Fujinon, Tokyo, Japan) device. Families provided verbal and written consent before the endoscopy. All patients were fasted for at least 6 hours before endoscopy. The anesthesiologists administered midazolam (0.1 mg/kg), ketamine (1 mg/kg), or propofol following local anesthesia with pharyngeal xylocaine. Once the patient was sedated, endoscopic procedures were performed. During endoscopy, the esophagus, cardia, fundus, corpus, and antrum regions of the stomach and duodenum were examined in detail. Pyloric dysfunction and gastric emptying were analyzed. During the endoscopic examination, signs of gastritis, hyperemia, fragility, edema, nodularity, gastric and duodenal ulcers, erosion, mass, bleeding, hiatal hernia, lower esophageal sphincter, and duodenogastric reflux (alkaline reflux) were examined and recorded. Endoscopy data for each patient were registered in a catalog of written documents and photographs.
At least two biopsy samples were taken from the esophagus, stomach corpus, antrum regions, and duodenum during the endoscopy procedure. Biopsies taken from the antrum and corpus were evaluated especially for the presence of H.pylori. Biopsy samples were fixed in 10% neutral buffered formalin. Hematoxylin-eosin and giemsa staining were performed by the pathology department. It was marked with periodic acid schiff and alcian blue (PAS-AB) for the evaluation of H. pylori and the presence of intestinal metaplasia. Histopathological evaluation was carried out per Sydney classification [8,9].
Statistical Package for Social Sciences (SPSS) Version 20.0 was used. The normality condition was checked with the Kolmogorov-Smirnov test. The relationship between qualitative variables was investigated using the chi-square analysis. Age of nausea and vomiting, epigastric pain, postprandial fullness, and bloating groups were compared with the Kruskal- Wallis H test since age values among the groups did not follow normal distribution. Therefore, the descriptive statistics of this variable among the groups were displayed as median (25% – 75% percentiles). Descriptive statistics for qualitative variables were expressed as frequency (n) and percent value (%). A p-value of <0.05 was considered statistically significant.
This retrospective observational study included 163 Pediatric patients aged between 7 and 18 years; 68 patients (41.7%) were male, and 95 (58.3%) were female. The mean age of the patients was 13.34±2.41 years.
There was no significant difference in terms of age or gender based on the complaints of the patients (p=0.552 and p=0.339, respectively). The patients were divided into four groups based on their complaints. The most common complaints were epigastric pain 32.5% and postprandial fullness 30%. The most common endoscopy findings were antral hyperemia (42.3%) and antral nodularity (21.4%) (Table 1). Endoscopic findings were found to be normal in 17.7% of the patients. Esophagitis was detected in 14.1% of the patients who applied with dyspeptic complaints. The most common esophagitis and alkaline reflux were observed in patients with epigastric pain. There was no statistically significant correlation between the patients’ initial complaints and the endoscopy findings (p=0.809).
The most common pathology findings were antral gastritis (46.6%) and pangastritis (30.6%). Esophagitis was most common in patients with epigastric pain. Eosinophilic and reflux esophagitis were also most frequent in patients with epigastric pain. Eosinophilic esophagitis and reflux esophagitis were observed in 4.2% and 9.8% of the cases, respectively. The pathology results of 13.4% of the patients with dyspeptic complaints were found to be normal. (Table 2). H.pylori was positive in 44.1% of the patients. There was no statistically significant relationship between the complaints at admission and the pathology findings.
When H. Pylori positive and negative patients were compared, the most common endoscopy finding was antral hyperemia (51.4%) and antral nodularity (27.8%). The presence of H. Pylori was associated with esophagitis in endoscopy and pathology. Eosinophilic esophagitis and reflux esophagitis were more common in H.pylori-positive patients. However, no correlation was found in patients with positive H.pylori in terms of the type of esophagitis (Table 3).
19% of the pediatric population complain of chronic or recurrent abdominal pain. Only 10% of these have findings for a specific diagnosis . In this study, antral gastritis was detected in 47.2% of pediatric patients with epigastric pain, 35.8% had pangastritis, and histopathology results were normal in 9.4% of the patients. This finding supports the fact that abdominal pain due to functional dyspepsia is also common in children..Endoscopic imaging of the upper gastrointestinal tract is a simple, less time-consuming, and low-complication diagnostic tool, which makes it possible to observe macropathologies, start necessary treatment, and obtain a biopsy for micropathologies, especially H.pylori [11,12]. The nodular and hyperemic feature of the mucosa in the antrum of the stomach, and the endoscopic appearance, which is sometimes called the salt-and-pepper appearance, is highly associated with H.pylori gastritis [13,14]. In our study, antral hyperemia was associated with H.pylori (p=0.002). In a study conducted with pediatric patients, antral nodular appearance was found in 48 (52%) patients with H.pylori gastritis, antral hyperemia was detected in 27 (29%), and a normal endoscopic image in the antrum and corpus was the case in 18 (19%) patients . In a study conducted in Turkey, the most common endoscopic finding in patients infected with H. pylori was reported as erythematous pangastritis (82%) . In a study by Ozcay et al.  on 102 children with H.pylori gastritis, 66 (64.7%) had an antral nodular appearance, 6 (5.9%) antral hyperemia, 2 (1.96%) duodenal ulcer, and 28 patients had normal endoscopic findings (27.5%). It shows us the importance of taking a biopsy sample if H.pylori is suspected, even if the macroscopic appearance is normal during upper GI endoscopy as H.pylori can cause dyspeptic complaints by functionally affecting GIS without causing pathological disorders in the GIS. Moreover, in this study, improvement in abdominal pain and dyspeptic complaints were observed with H.pylori eradication treatment. Symptomatic H. pylori infections should be treated for preventing complications of H. pylori in children and adults.
Duodenogastric reflux (DGR) or alkaline reflux is the passage of duodenal contents from the duodenum to the stomach. Although DGR is quite common after cholecystectomy, pyloroplasty, and gastric surgery, it can also develop primarily due to pyloric insufficiency without a secondary cause. Complaints such as epigastric pain, pain in the retrosternal region, and bile vomiting may develop after DGR, or they may be asymptomatic. Ulceration, erosion, hyperemia, and excessive bile in the stomach (especially in patients with abdominal pain) in upper GI endoscopy are the clinical findings of DGR. However, it is still unclear whether primary DGR causes histopathological changes in the upper GIS in children . It has been reported that short-term reflux of duodenal contents into the stomach during physiological events may rarely cause symptoms. Taşkın et al.  found no significant difference between patients with and without DGR concerning chronic inflammation in the gastric biopsy. There are conflicting results concerning the prevalence of H.pylori in children with DGR. In this study, there was no relation between the presence of H.pylori and alkaline reflux. Similarly, in another study, no statistically significant difference was detected between groups with and without DGR in terms of H. pylori prevalence or density . On the other hand, Adam et al.  reported that DGR (alkaline reflux) elevated H.pylori in their study involving 1120 pediatric patients.
Nausea and vomiting are associated with H. pylori infection in studies conducted in developing countries . A cross-sectional seroepidemiological study conducted in school children in Italy suggested that nausea and vomiting were positively associated with H. pylori infection (OR 2.2) . In our study, a significant relationship between esophagitis and H.pylori is also evident. This situation can be attributed to H.pylori increasing dyspeptic symptoms and causing inflammatory response. In recent studies, the relationship between eosinophilic esophagitis and H.pylori is also noteworthy . The incidence of Eosinophilic esophagitis in children under the age of 18 who underwent upper GI endoscopy due to abdominal pain was as high as 6%; 3.7% of 376 children who had resistant dyspeptic symptoms were diagnosed with eosinophilic esophagitis resistant to treatment . Similarly, in our study, the prevalence of eosinophilic esophagitis was 4.2% in children with dyspeptic complaints.
This study presents certain limitations. The patients could be divided into groups based on the duration and severity of dyspepsia for intergroup comparisons. In addition, organic and functional dyspepsia could be compared in terms of H.pylori, and its features could be brought to discussion. Therefore, studies with longer duration and higher number of patients are necessary.
Today, chronic dyspepsia is common in the childhood age group, and in cases where no response to treatment is obtained, endoscopic imaging of the upper gastrointestinal tract and biopsy should be taken. H. Pylori is also common in children with chronic dyspeptic complaints. H.pylori should also be investigated in cases of dyspepsia that are unresponsive to proton pump inhibitors and H2-receptor blockers.
The relation of H.pylori with diseases such as autoimmune gastritis and eosinophilic esophagitis, in which inflammation is at the forefront, continues to be a subject of investigation. In this study, the relationship between esophagitis and H.pylori draws particular attention.
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16. Gurbuz BC, Inceman HN, Aydemir M, Celtik C, Gerenli N, Zemheri E. Prevalence of Helicobacter pylori among children in a training and research hospital clinic in Istanbul and comparison with Updated Sydney Classification Criteria. North Clin Istanb. 2020;7(5):499-505.
17. Ozçay F, Koçak N, Temizel IN, Demir H, Ozen H, Yüce A, et al. Helicobacter pylori infection in Turkish children: comparison of diagnostic tests, evaluation of eradication rate, and changes in symptoms after eradication. Helicobacter. 2004;9(3):242-8.
18. Chen L, Zhu G, She L, Ding Y, Yang C, Zhu F. Analysis of Risk Factors and Establishment of a Prediction Model for Endoscopic Primary Bile Reflux: A Single-Center Retrospective Study. Front Med. 2021;8:758-71.
19. Taşkin V, Sedele M, Saka O, Kantarçeken B. The effect of duodenogastric reflux on Helicobacter pylori presence and gastric histopathologic changes. Turk J Gastroenterol. 2003;14(4):239-42.
20. Agin M, Kayar Y. The Effect of Primary Duodenogastric Bile Reflux on the Presence and Density of Helicobacter pylori and on Gastritis in Childhood. Medicina (Kaunas) 2019;55(12):775.
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22. Ozen A, Ertem D, Pehlivanoglu E. Natural history and symptomatology of Helicobacter pylori in childhood and factors determining the epidemiology of infection. J Pediatr Gastroenterol Nutr. 2006;42(4):398-404.
23. Dore MP, Fanciulli G, Tomasi PA, Realdi G, Delitala G, Graham DY, et al. Gastrointestinal symptoms and Helicobacter pylori infection in school-age children residing in Porto Torres, Sardinia, Italy. Helicobacter. 2012;17(5):369-73.
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Meryem Keceli Basaran, Yilmaz Secilmis. Evaluation of endoscopy and pathology findings in pediatric patients with chronic dyspeptic complaints. Ann Clin Anal Med 2022;13(Suppl 1): S21-25
Tracheostomy experiences in an adult anesthesia intensive care unit
Department of Anesthesiology and Reanimation, Health Sciences University, Ahi Evren Training and Research Hospital, Trabzon, Turkey
DOI: 10.4328/ACAM.21100 Received: 2022-02-08 Accepted: 2022-03-14 Published Online: 2022-03-14 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S26-30
Corresponding Author: Gönül Erkan, Department of Anesthesiology and Reanimation, Health Sciences University, Ahi Evren Training and Research Hospital, Trabzon, Turkey. E-mail: firstname.lastname@example.org P: +90 505 375 40 93 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2028-4288
Aim: This study aimed to present the tracheostomy procedures in patients treated in the adult anesthesia intensive care unit (ICU) of our clinic.
Material and Methods: Patients who admitted to the adult anesthesia ICU of our hospital and underwent surgical and percutaneous tracheostomy between January 2012 and January 2019 were retrospectively evaluated. The demographic data of the patients, diagnosis upon ICU hospitalization, Glasgow coma scale score, acute physiological and chronic health assessment results, length of stay with tracheostomy, duration of tracheostomy procedure, method of tracheostomy (percutaneous or surgical), complications, and mortality rates were investigated.
Results: The data of 114 patients were analyzed. Among patients with a mean age of 72.03 ± 14.12 years, 41.23% were females, and 58.77% were males. At ICU admissions, the most common diagnoses were pulmonary pathologies in 29.82%, cardiovascular diseases in 25.44%, and cerebral pathologies in 20.18%. The mean length of stay of the patients after the tracheostomy procedure was 17.09±7.22 days. Seventy-two (63.16%) patients underwent percutaneous tracheostomy, and 42 (36.84%) underwent surgical tracheostomy. The mean tracheostomy procedure duration was 12.82±8.04 minutes; 19 (16.67%) patients had complications, mostly bleeding. The overall mortality rate was 25.44%, most seen among the patients with cardiovascular diseases (81.82%). Of the tracheostomized patients, 53.51% were transferred to palliative care and other services, and 21.05% were discharged as home care patients.
Discussion: The tracheostomy procedure is crucial in the transfer or discharge of patients hospitalized in the adult intensive care unit with home-type mechanical ventilators or spontaneous breathing.
Keywords: Tracheostomy, Intensive Care Unit, Patient, Complication
For the continuation of artificial respiration and maintenance of airway patency, endotracheal intubation is currently the first option in ICUs today. When the clinical course of inpatients in the ICU improves, the patient can be extubated. However, some patients may require artificial respiratory support for several weeks and sometimes months. The recommendation to perform tracheostomy as an alternative to intubation in patients who underwent intubation and are expected to need prolonged mechanical ventilation has taken its place in the literature. The complications of long-lasting endotracheal intubation have been investigated, and the necessity of a tracheostomy has been revealed. Tracheostomy is performed to reduce complications of long-term endotracheal intubation, including vocal cord paralysis, glottic or subglottic stenosis, laryngeal damage and infection . Protecting the airway in patients in the ICU, easy cleaning of tracheal secretions, reducing the dead space volume, shortening the length of stay in ICU, facilitating oral feeding, increasing patient comfort are among the other reasons for performing a tracheostomy . The tracheostomy procedure has been a lifesaver in upper airway obstructions due to trauma, foreign body aspiration, and infections for a long time in human history. References indicate that the first tracheostomy was performed in the 100th year BC by Greek doctor Asclepiades. Jackson first performed the standard surgical tracheostomy in 1909, and the first modern percutaneous tracheostomy was reported by Shelden et al. in 1955. Tracheostomy is performed with two techniques. The percutaneous dilatational tracheostomy technique was developed by Ciaglia et al., and the percutaneous guidewire dilatational tracheotomy technique was developed by Griggs et al. . Tracheostomy is applied by surgical or percutaneous methods today. There are publications in the literature that include comparisons and experiences with tracheostomy [4-7]. This study aimed to retrospectively evaluate the tracheostomies conducted in the adult anesthesiology and reanimation ICU and contribute to the literature with this experience.
Material and Methods
Study Plan and Patient Selection
A total of 114 patients who were hospitalized in the adult ICU and underwent percutaneous or surgical tracheostomy between January 2012 and January 2019 were retrospectively analyzed. The data of the patients were acquired from the hospital data processing system and patient files. The study included patients over 18 years of age who were treated in our anesthesiology ICU and underwent a tracheostomy procedure. Individuals aged ≤ 18 years, whose data were missed, and patients who underwent an emergency tracheostomy procedure were excluded. The demographic data of the patients, ICU admission diagnoses, Glasgow coma scale (GCS) scores at admission to the ICU, acute physiological and chronic health evaluation (APACHE 2), and other relevant data were analyzed. The length of stay with the tracheostomy, duration, and the method of the tracheostomy procedure (percutaneous or surgical) were recorded. Reasons for the preference of the surgical method, the duration of the procedure, and complication rates were compared between the percutaneous and surgical tracheostomy groups. Complications were categorized as early and late, according to whether they occurred during or after the procedure. Bleeding that did not stop within a short time with sponges wrapped around the stoma and/or blood aspiration through the tracheostomy tube were considered minor bleeding. Continued bleeding from the stoma and/or aspiration of blood from the tracheostomy, despite compression were considered major bleeding. Only major bleeding patients were included in the bleeding complication rate calculation. The reasons for the termination of the ICU treatments of the patients (discharged as a home care patient, transfer to the wards, mortality) were investigated. The current respiratory status of the patients (not tracheostomized and spontaneous respiration, tracheostomized and spontaneous respiration, receiving home-type mechanical ventilator support without spontaneous respiration) was documented.
Routine Tracheostomy Procedure
The patients whose consent was obtained for the tracheostomy procedure were monitored with electrocardiography, pulse oximetry, and invasive arterial pressure with (end-tidal carbon dioxide) EtCO2 . Before the tracheostomy procedure, the patients were administered fentanyl (2 μg/kg) (Talinate, Ibrahim Etem Pharmaceuticals, Turkey), midazolam (0.1 mg/kg) (Sedazolam, Monemfarma Pharmaceuticals, Turkey), and rocuronium (0.5 mg/kg) (Myocron, Vem Pharmaceuticals, Turkey) intravenously. The patients were supported by positive pressure mechanical ventilation with 100% oxygen. After the endotracheal tube cuff was deflated in the patients who received a percutaneous dilatational tracheostomy, it was retracted until below the vocal cords. The space between the second and third tracheal rings was palpated. After a vertical incision, the tracheal lumen was cannulated with a 14 G needle. A guidewire was placed in the lumen; the needle was withdrawn and expanded with an 8F dilator. The skin, subcutaneous tissue, and the trachea were dilated with forceps, and a tracheostomy tube was placed in the trachea. After the cuff was inflated, respiratory sounds were auscultated, and the cannula location was evaluated. The patients in whom a fiberoptic bronchoscope was used during the procedure were noted. In the patients who underwent surgical tracheostomy, the space between the second and third tracheal rings was palpated, and the skin was incised. The subcutaneous tissue, superficial fascia, platysma muscle, superficial layer of the deep fascia, infrahyoid muscles, visceral fascia, thyroid gland, and pretracheal fascia were dissected to reach the trachea. The endotracheal tube was retracted until below the vocal cords after the cuff was deflated. The cannula was placed in the trachea after incision and aspiration. The endotracheal tube was removed after the cuff was inflated, breathing sounds were auscultated, and the location of the cannula was confirmed. After the procedures, the chest X-rays of the patients were taken at the bedside.
The data were analyzed with IBM SPSS 25.0 (Statistic Inc. version Chicago, IL, USA) software. Descriptive statistics were presented as mean ± standard deviation values for continuous variables, and categorical variables were expressed in frequency and percentage (%). The duration of the procedure in the patients who underwent percutaneous and surgical tracheostomy was compared using the independent samples t-test, while the overall complication rates between these two groups were compared using the chi-square analysis method. Results were considered significant at 95% confidence intervals and at p < 0.05.
The data of 114 patients were analyzed. The demographical data of the patients, GCS, APACHE 2 scores, and ICU admission diagnoses are summarized in Table 1.
The mean length of stay in the ICU was 50.03±19.81 days. The mean hospital stay of the patients until the tracheostomy procedure was 17.09±7.22 days. Seventy-two patients (63.16%) underwent percutaneous tracheostomy, and 42 patients (36.84%) underwent surgical tracheostomy. The mean tracheostomy procedure duration was 12.82±8.04 minutes. Among the patients who underwent surgical tracheostomy, 10 (8.77%) were morbidly obese, 9 (7.89%) had a neck mass, 9 (7.89%) underwent a retracheostomy, 6 (5.26%) had anatomical deformations, 5 (4.39%) had early complications related to a percutaneous tracheostomy, and 3 (2.63%) had no specific indications.
Among all patients, 19 (16.67%) had complications, of which 10 (8.77%) had early tracheostomy complications. Four patients (3.51%) had major bleeding, 2 (1.75%) had pneumothorax, 2 (1.75%) had paratracheal cannulas and ventilation leak, 1 (0.88%) had emphysema. Mortality was observed in 1 patient (0.88%) due to the tracheostomy procedure. Late complications were detected in 9 (7.89%) patients. Four patients (3.51%) had tracheal stenosis, 2 (1.75%) had wound infection, 2 (1.75%) had tracheoesophageal fistulae, and 1 (0.88%) had tracheo-innominate artery fistula. The outcomes of the tracheostomy procedures and the respiratory statuses at transfer to another ward or discharge are summarized in Table 2.
The duration of the procedure in the patients who underwent percutaneous and surgical tracheostomy was compared. The mean duration of the procedure was 8.90±5.32 in the percutaneous tracheostomy group, 19.55±7.48 in the surgical
tracheostomy group, and the difference was statistically significant (p<0.05). A fiberoptic bronchoscope was used in 36 (50%) patients who underwent percutaneous tracheostomy. The overall complication rate in the patients who underwent tracheostomy was 21.93%, while 22.22%, and 21.43% in those who underwent percutaneous and surgical tracheostomy, respectively (p>0.05).
The mortality rates were evaluated according to the diagnosis upon ICU hospitalization (Table 3). Accordingly, mortality was observed in 81.82% of the patients hospitalized due to cardiovascular diseases, 40% of the patients with chronic organ failure, 20.69% of those with cerebral pathologies, 17.39% of the patients hospitalized due to surgical complications, and 5.88% of those hospitalized due to pulmonary pathologies. On the other hand, no mortality was observed in the patients hospitalized in the ICU due to neuromuscular diseases and trauma.
Tracheostomy is preferred in endotracheal intubation to facilitate weaning and for patients in whom mechanical ventilation support is expected to last long [1,8]. Indications of tracheostomy include weaning failure, difficult airway, prolonged mechanical ventilation need, upper airway obstruction and the presence of excessive, obstructive secretions in the trachea. In addition, patients with acute cerebral injury and/or acute respiratory failure frequently need a tracheostomy. A study reported the hospitalization diagnoses, which were tracheostomy indications as acute respiratory failure (56.5%), chronic obstructive pulmonary (6.2%), and coma (5.1%) . Şeker et al. reported the hospitalization diagnoses for tracheostomy as central nervous system pathologies (29%), polytrauma (21%), intra-abdominal sepsis (17%), respiratory system pathologies (13%), multiple organ failure (10%), and cardiopulmonary resuscitation (2.4%) . While respiratory failure was the most common diagnosis in their first study, in the second study of Şeker et al. central nervous system pathologies were at the forefront. In our study, the most common hospitalization diagnosis was respiratory failure pathologies. In addition, the fact that ours is a branch hospital for cardiological patients also highlights cardiological pathologies in hospitalization, which is a tracheostomy indication (Table 1). Regarding the duration of the tracheostomy procedure, it is difficult to recommend a standard time period according to patient groups and diagnoses. The responsible clinician can make this decision after evaluating the patient and the clinical situation. However, in the presence of pathology (neurological damage, progressive muscle diseases, medulla spinalis injuries, masses causing airway obstruction) that renders extubation difficult within a short time, the best approach would be to perform a tracheostomy as soon as possible after admission to the intensive care unit and intubation. There are studies on the performance time in the ICUs [10,11]. For example, a study in England analyzed the data of 178 cases and found that tracheostomies were performed in the first week of hospitalization in half of the patients, and the second week and later in the other half . In a different study, early and late tracheostomy performance times were evaluated separately. Early tracheostomies were executed in 7.60±4 days and late tracheostomies, in 17.40±5.30 days, with a longer intensive care unit stay in patients who underwent a late tracheostomy . We found that a tracheostomy was performed within 17.09±7.22 days of admission to our ICU, similar to that of the patients who received a late tracheostomy in the aforementioned study (Table 2). The percutaneous technique is preferred for patients hospitalized in the intensive care unit because it can be applied at the bedside, the perioperative and postoperative complication rates are lower, and the procedure time is short. Mirski et al. reported that percutaneous tracheostomy is the most frequently preferred technique and that its use has been increasing gradually over the years (from 46.2% in 2004 to 77.2% in 2008) . In an international multicenter study conducted by Maria et al. in 2015, the rate of percutaneous tracheostomy was higher (63.16%), consistent with the literature . In a study comparing percutaneous and surgical tracheostomy, the durations of the procedures were 6.19±0.54 minutes and 32.07 ± 2.86 minutes, respectively . In another study, the duration of percutaneous dilatational tracheostomy was 12.4 ± 3.2 minutes, and that of surgical tracheostomy was 21.2 ± 2.9 minutes . The results in the literature are similar to the results of our study, and the duration of percutaneous dilatational tracheostomy is shorter than surgical tracheostomy. According to the literature, tracheostomy complications can be classified as early and late complications. While bleeding, pneumothorax, emphysema, paratracheal insertion of the cannula, and cardiac arrest are early complications, tracheo-innominate artery fistula, tracheal stenosis, tracheoesophageal fistula and wound infections are late complications [15,16]. Cırık et al. investigated the results of percutaneous tracheostomy in 96 patients and found an early complication rate of 17.7 %. They stated that the most common complication was bleeding in 11 (%11.4) patients . In a meta-analysis, bleeding and stoma infection were reported to be more common in patients who underwent surgical tracheostomy . Incorrect and difficult placement of the tracheostomy cannula, hypoxia, loss of airway control, and related death were higher in percutaneous tracheostomy In a retrospective study of 115 patients who underwent percutaneous tracheostomy with the Griggs method, the early complications were minor bleeding, surgical bleeding, and incorrect cannula placement with the rates of 2.6%, 0.86%, and 0.86%, respectively . In the study by Demirel et al. 52 patients with tracheostomy were evaluated, 5 patients had early complications (9.6%), and bleeding was the most common . In another study by Düger et al., it was concluded that the percutaneous tracheostomy method gave better results than the surgical tracheostomy method in terms of oxygenation, complications and bleeding in the early postoperative period, and that many factors such as the urgency of the tracheostomy and the experience of the person and the clinic affected the complication rate . Bleeding, pneumothorax, emphysema, paratracheal cannula placement, and cardiopulmonary arrest due to ventilation leak were the early complications among our ICU patients. The most common complication was bleeding, whereas tracheal stenosis was the most common late complication. Other late complications included tracheo-innominate artery fistula, wound infection, and tracheoesophageal fistula. During transfer to the ward or at discharge, 12 (10.53%) patients were spontaneously breathing and decannulated, 9 (7.89%) patients were spontaneously breathing without decannulation, and 64 (56.14%) patients were receiving home-type mechanical ventilator support. The remaining 29 (25.44%) patients died. There are various studies investigating the mortality rate among ICU patients who underwent tracheostomy. Diaz et al. reported a 30% mortality rate in the ICU . In the study by Lin et al. on patients who needed mechanical ventilation for more than 14 days, the mortality rate in the ICU was 17% among the tracheostomy patients . The 25.44% mortality rate found in our study is close to the results reported in the literature. ICU admission diagnoses are factors that affect mortality, and the highest mortality rate was 81.82% witnessed in the patients hospitalized in the ICU due to cardiovascular diseases. It is thought that the fact that our hospital is a reference center for cardiovascular diseases affected this result. The limitations of our study include its retrospective nature and the fact that our hospital was a branch hospital.
The tracheostomy outcomes in our clinic meet international standards in terms of both complications and mortality. The tracheostomy procedure is an important factor in transferring the patient to the ward or discharge with a home-type mechanical ventilator or spontaneously breathing.
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Animal and human rights statement
Conflict of interest
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7. Doğan M, Taş S. 3. Basamak Sağlık Kuruluşunda Trakeotomi Açılan Hastaların Analizi (Analysis of Patients with Tracheotomy in a 3rd Level Health Institution). KBB-Forum/ ENT-Forum. 2020;19(1): 98-105.
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Download attachments: 10.4328:ACAM.21100
Gönül Erkan. Tracheostomy experiences in an adult anesthesia intensive care unit. Ann Clin Anal Med 2022;13(Suppl 1): S26-30
Lateral closed wedge versus reverse-V osteotomy for cubitus varus: A saw-bone study
Murat Kaya 1, Nazım Karahan 2
1 Department of Orthopedics and Traumatology, Marmara University, Pendik Training and Research Hospital, Istanbul, 2 Department of Orthopedics and Traumatology, Çorlu District State Hospital, Tekirdag, Turkey
DOI: 10.4328/ACAM.21125 Received: 2022-02-23 Accepted: 2022-03-13 Published Online: 2022-03-14 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S31-35
Corresponding Author: Murat Kaya, Fevzi Çakmak, Department of Orthopedics and Traumatology, Marmara University, Pendik Training and Research Hospital, Muhsin Yazıcıoğlu Cd., No: 10, 34899, Pendik, İstanbul, Turkey. E-mail: email@example.com P: +90 532 565 62 32 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8751-9603
Aim: In this study, we aimed to perform a biomechanical comparison of Lateral Closed Wedge (LCW) osteotomy and Reverse-V osteotomy techniques in cubitus varus surgery.
Material and Methods: Thirty-six anatomical humerus models were used. Osteotomy was performed with a 2 mm oscillating cutter motor on the templates prepared as Group 1 (LCW osteotomy) and Group 2 (Reverse-V osteotomy). Fixation was achieved with three crossed Kirschner’s wires (K-Wires), two lateral and one medial. The translation was measured using a digital caliper. Models were tested in flexion load, varus load, and valgus load at a speed of 0.5 mm/s and a displacement range of 0-5 mm. Loading (N) and Hardness (N/mm) data were calculated and compared statistically.
Results: Mean translation in Group 1 [T1:7.91±0.65 mm (6.8-9mm)] was higher than that in Group 2 [T2:4.47±0.68 mm (3.5-8mm)] (P<0.001). Flexion load, varus cyclic load, and stiffness in Group 1 were higher than Group 2 (P<0.001). No significant difference between the groups in valgus cyclic load and stiffness was found (P<0.419).
Discussion: It was observed that LCW osteotomy was a more rigid system in varus and flexion compared to the Reverse-V osteotomy technique, but there was no biomechanical difference in valgus.
Keywords: Valgus Cyclic Load, Cubitus Varus Surgery, Varus Cyclic Load
Supracondylar humerus fractures are the most common elbow fractures in childhood . Deformities and movement restrictions may be observed in untreated cases . Cubitus varus is the most common late complication with 3-57% [3,4]. Cubitus varus can cause functional and cosmetic problems in the elbow . In addition, surgery is the treatment option in cases with a higher risk of lateral condyle fracture, triceps tendon and ulnar nerve dislocation, posterolateral rotational instability of the elbow, and delayed ulnar nerve palsy [6,7].
Many osteotomy techniques and fixation methods have been described in the literature for cubitus varus deformity. However, there is no gold standard treatment yet . LCW osteotomy, Medial Open Wedge (MOW) osteotomy, Dome osteotomy, and Step-cut osteotomy are commonly used surgical techniques [9–12]. LCW osteotomy is widely used because of its ease of application. However, increased prominence in the lateral condyle is a common complication in long-term follow-up [13,14]. To reduce these complications, a traditional step-cut osteotomy was defined by De Roza and Graziano . Subsequently, Yun et al. modified the Step-cut osteotomy technique and described the Reverse-V osteotomy technique to provide better fixation and create a medial-lateral wall sufficient to fix the distal fragment . Although there are clinical case series about these osteotomy techniques in the literature, the number of patients is deficient, and studies comparing osteotomy techniques are very few .
In this study, the LCW osteotomy technique was used frequently in the literature, and the Reverse-V osteotomy technique, considered more stable in clinical studies, were biomechanically compared.
Material and Methods
The local Clinical Research Ethics Committee approved the study (Approval date and number: 28.0I.202l/02). Power analysis was performed using the G*Power (v220.127.116.11) program and the sample size was determined. To achieve 80% power at the α=0.05 level, six subjects were required in each group decided to work. A single orthopedic surgeon performed the entire procedure on each model. Osteotomy models and fixations were performed in the Marmara University Orthopedic Surgery Department. Biomechanical tests were performed in Dokuz Eylül University Biomechanics Laboratory.
Study design and Variables: Two-group comparative biomechanical studies:
LCW osteotomy (Group 1), Reverse-V osteotomy (Group 2). The pediatric humerus sawbones model with the same shape, size, and side was the constant variable in the study. Other constant variables were the applied fixation material and technique. The independent variable is the corrective osteotomy technique and post-fixation durability.
In the study, 36 anatomical humerus models suitable for the pediatric age group were used. Two groups were formed, containing 18 specimens (Sawbones #1052, pediatric humerus 26 cm, Pacific Research, Vashon Is., WA, USA).
Course of the study:
In 36 humerus sawbones models, the entry and exit locations of the lateral and medial fixation K-wires were determined by standardizing in the posterior-anterior (PA) drawing. The anatomical axis line (x) and the widest metaphyseal distance perpendicular to the anatomical axis (y) were determined. The distance from the medial endpoint of the metaphyseal widest distance (y) detected before osteotomy to the medial cortex after osteotomy was determined as the amount of translation. The diagram of the distal humerus LCW osteotomy, the translation measurement and Antero-Posterior (AP) x-ray image after reduction and fixation are given in Figure-1. The diagram of the distal humerus Reverse-V osteotomy, translation measurement and AP x-ray image after reduction and fixation are given in Figure-2.
In both groups, osteotomies were performed using a 2 mm oscillating cutter motor on the templates prepared to achieve 30 degrees of valgization. Following the reduction, the K-wires (Three Straight K-wires, 1.6 mm diameter; TST Medical, Istanbul, Turkey) are placed at the predetermined fixation points as two lateral and one medial to ensure adequate fixation (using a custom-made apparatus to minimize inconsistencies) [3,17]. The distance between the anatomical bone model and the medial cortices of the bone models after fixation was measured using a digital caliper (IP-67, 0.01mm/0.0005”, INSIZE, Istanbul), and the Translation (T) amounts were determined as T1 for LCW osteotomy and T2 for Reverse-V osteotomy. Each model was then cut transversely from the fixed point in the mid-diaphysis to isolate the distal humerus. Each sawbones was then embedded in a plastic template containing liquid epoxy resin designed to rigidly hold both proximal and distal parts and allowed to become rigid. Mechanical analysis was carried out by fixing the plastic jar to a cylindrical metal with a mechanical compression system.
Mechanical comparison was performed with a universal measuring machine (Shimadzu Autograph 50 kN; Shimadzu Corp). Models were tested in three cycles. Applying force to only one point of the device was prevented by turning the distal joint interface prepared using epoxy resin to the relevant planes. Six models were used for each sample in bending mechanical loading to the humerus, and the force required to be applied at a speed of 0.5 mm/s and a displacement of 0-5 mm was calculated for each configuration. Force and displacement were measured (precision with an accuracy level of 0,1N and 0,01mm). Hardness was calculated according to the slope of the force-displacement curve of three cycles for flexion-varus-valgus measurements. Microsoft Excel (Microsoft Corp., Redmond, WA) software calculates the hardness value (N/mm).
IBM SPSS Statistics 22 (IBM Corp.; Armonk, NY, USA) program was used for statistical analysis. The Mann-Whitney U test was used to determine the difference in displacement applied force and hardness between osteotomy groups. A p-value of <0.05 was considered statistically significant. Deviation data against the load were obtained automatically during loading. Displacement versus load showed a linear behavior.
Flexion-varus-valgus mean bending cyclic load values are shown in Table-1. Flexion and varus bending cyclic load values were significantly higher in Group 1 compared to Group 2 (P<0.001). There was no significant difference between the groups regarding valgus bending cyclic load values (P<0.419). The mean stiffness values developed against cyclic loading in flexion-varus-valgus bending applied in all osteotomy models are shown in Table-2. The stiffness values developed in flexion and varus bending cyclic loading were significantly higher in Group 1 than Group 2 (P<0.001). There was no significant difference between the groups regarding the stiffness value developed under cyclic loading of valgus bending (P<0.467). The mean translation was T1 7.91±0.65 mm (6.8-9mm) in Group 1 and T2 4.47±0.68 mm (3.5-8mm) in Group 2; the translation was significantly higher in Group 1 than Group 2 (P<0.001). During cyclic loading tests, neither pin loosening nor reduction loss was observed in either group.
Contrary to the view in the literature that the Reverse-V osteotomy has a natural stability against varus and valgus forces thanks to the medial and lateral column effect , in our study, it was observed that the LCW osteotomy technique was more durable than the Reverse-V osteotomy technique in varus and flexion cyclic loading. No significant difference between the groups in valgus cyclic loading was determined.
Cubitus varus is an elbow deformity that causes biomechanical instability due to medial displacement of the mechanical axis. In LCW osteotomy, one of the classical corrective surgical techniques, angular corrections are calculated by preoperative planning, while the surgeon adjusts mechanical axis correction after osteotomy . In addition, since the classical LCW osteotomy technique does not involve medial translation, it may cause cosmetic problems such as the prominence of the lateral condylar protrusion due to the lateral translation of the distal part . In a Reverse-V osteotomy, which is defined to solve this problem, mechanical axis correction, angle, and placement of the wedge to be removed are calculated with preoperative planning; angular fragments are reduced after osteotomy [16,19]. In addition, lateral condylar prominence is less common than classical LCW osteotomy, since the distal part is technically reduced and translated medially . In our study, osteotomy techniques were used for the standardization of osteotomy lines and angles. The translation amounts of both groups were measured after reduction. As a matter of fact, in our study on model bones, we found that the amount of lateral translation in LCW osteotomy was higher than the amount of lateral translation in Reverse-V osteotomy in the measurements made after osteotomy and reduction procedures. Although technically combining Reverse-V osteotomy with medial translation has advantages, there is a need for biomechanical and clinical studies of different plans. It will cause changes in the biomechanical strength of the models.
Elbow arthrofibrosis is a common complication after elbow osteotomy. Immobilization is the most common cause of elbow arthrofibrosis after cubitus varus surgery. Therefore, stabilization allowing early movement is one of the most critical points for successful functional results in cubitus varus correction surgery . In cases where adequate stabilization is not provided, the prevention of early joint movement to prevent reduction loss adversely affects functional outcome. To address this problem, clinical studies have been conducted on combining osteotomy techniques with different stabilization methods [14,21]. Our study, which is the first experimental study to compare two osteotomy techniques with the same stabilization, found that the LCW osteotomy offers a more rigid fixation than the Reverse-V osteotomy, which emphasizes its natural stability by providing medial and lateral column support. We thought that this might be the difference in the translation amount of the vector distribution. In addition, we predicted that due to the configuration of the Reverse-V osteotomy, the part removed from the distal medial and the cortical surface forces remaining in the proximal medial could change the moment center.
In Cubitus Varus surgery, K-wires, Steinmann pins, screws and cerclage, K-wires supported with tension band, plates, and screws, and external fixators are frequently used as fixation methods after osteotomy [6,14,22]. K-wire fixation is a fixation tool that is easy to use in children with open physis and can be easily removed after union . In the literature, it has been shown that two lateral and one medial K-wires are more rigid than other systems in patients with supracondylar fracture model [3,17,23]. Studies investigating the effect of wire diameter (1.6 mm vs. 2.8 mm) have shown that the resistance of thick K-wire is higher. On the other hand, it is emphasized that 2.8 mm wires are not clinically relevant due to the occasional use of wires over 1.6 mm and 2.0 mm in this age group . We used three smooth K-wires of 1.6 mm in a cross configuration, two lateral and one medial in line with this information. Sufficient stability was achieved with this fixation method, and no reduction loss of pin loosening was observed under cyclic loads in either group.
Sawbones is frequently used in biomechanical studies investigating the effect of wire configuration on strength in supracondylar fixation. Studies using cadavers rather than model bones are rare. Adult cadaver bone was used in these studies because of the difficulty in obtaining pediatric age cadavers . We also preferred to use pediatric humerus sawbones modeling in our study.
There are several limitations to our study. The anatomical model bone used in our study is not a deformity model in which osteotomy is defined may be insufficient to imitate biomechanics. In addition, it does not fully represent pediatric bone, as it does not take into account the peripheral anatomical structures that may contribute to fracture stability, such as the periosteum. In addition, the stress mechanisms applied in our study do not accurately reflect all the physiological stresses experienced by the elbow during recovery. However, the main benefit of using synthetic models is that they allow the isolation of the tested variables as they are uniform structures. In the comparison of osteotomy techniques and biomechanics, there are differences in surgical approaches, ease of application, wound healing, surgical time, and fixation difficulty. A clinical study evaluating all these would contribute significantly to the literature. Future research should focus on biomechanical studies on bone models in which the deformity is mimicked and on further clinical studies that also evaluate other factors.
It was determined that lateral translation was higher after reduction in the classical LCW osteotomy technique than the Reverse-V osteotomy technique. The LCW technique was more stable biomechanically in our sawbones model.
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4. Tellisi N, Abusetta G, Day M, Hamid A, Wahab KA, Ashammakhi N. Management of Gartland’s type III supracondylar fractures of the humerus in children: The role audit and practice guidelines. Injury. 2004;35(11):1167–71.
5. Kim HS, Jahng JS, Han DY, Park HW, Kang HJ, Chun CH. Modified step-cut osteotomy of the humerus. Journal of Pediatric Orthopaedics Part B. 1998;7(2):162–6.
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7. Eamsobhana P, Kaewpornsawan K. Double dome osteotomy for the treatment of cubitus varus in children. Int Orthop. 2013;37(4):641–6.
8. Bauer AS, Pham B, Lattanza LL. Surgical Correction of Cubitus Varus. J Hand Surg. 2016; 41(3): 447–52.
9. French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. The Lancet. 1959;274(7100):439–41.
10. King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg Am. 1951;33 A(3):572–6.
11. Kumar K, Sharma VK, Sharma R, Maffulli N. Correction of cubitus varus by French or dome osteotomy: A comparative study. J Trauma. 2000; 49(4): 717–21.
12. DeRosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin Orthop Relat Res. 1988; 236: 160–5.
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14. Ho CA. Cubitus Varus—It’s More Than Just a Crooked Arm! J Pediatr Orthop. 2017; 37(Suppl. 2): S37–41.
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16. Mishra PK, Verma AK, Dwivedi R, Singh SP, Gaur SC. Reverse V osteotomy and treatment of cubitus varus deformity – Results and experience. J Clin Orthop Trauma. 2016;7(Suppl. 2):154–60.
17. Azzam W, Catagni MA, Ayoub MA, El-Sayed M, Thabet AM. Early correction of malunited supracondylar humerus fractures in young children. Injury. 2020;51(11):2574–80.
18. Barrett IR, Bellemore MC, Kwon YM. Cosmetic results of supracondylar osteotomy for correction of Cubitus varus. J Pediatr Orthop. 1998;18(4):445–7.
19. Vashisht S, Sudesh P, Gopinathan NR, Kumar D, Karthick SR, Goni V. Results of the modified reverse step-cut osteotomy in paediatric cubitus varus. Int Orthop. 2020;44(7):1417–26.
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Murat Kaya, Nazım Karahan. Lateral closed wedge versus reverse-V osteotomy for cubitus varus: A saw-bone study. Ann Clin Anal Med 2022;13(Suppl 1): S31-35
An unexpected circumstance; clozapine-induced amenorrhea: A case report
Aslı Kazğan 1, Sevler Yıldız 2
1 Department of Psychiatry, Ministry Of Health, Siverek State Hospital, Şanlıurfa, 2 Department of Psychiatry, Medical Faculty, University of Binali Yıldırım, Erzincan, Turkey
DOI: 10.4328/ACAM.20522 Received: 2021-02-05 Accepted: 2021-04-08 Published Online: 2021-11-15 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S36-38
Corresponding Author: Aslı Kazğan, Ministry Of Health, Siverek State Hospital, Department of Psychiatry, 63600 Şanlıurfa, Turkey. E-mail: firstname.lastname@example.org P: +90 505 740 33 68 F: +90 414 553 31 95 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0312-0476
Most antipsychotic drugs employed in psychosis treatment can lead to amenorrhea and high prolactin levels in women. There are only a few studies on the overall impact of this adverse effect. Neglecting adverse effects of prescriptions in psychiatric follow-ups may cause loss of the sense of femininity, lack of birth control, and even premature menopause due to unrecognition of the menstrual cycle in women with psychosis. Clozapine is one of the antipsychotic drugs with the lowest accepted risk of hyperprolactinemia in therapeutic doses. Clozapine induced amenorrhea considered safe for hyperprolactinemia, is a rare condition. In the present study, we aimed to describe a clozapine-induced amenorrhea case and the clinical manifestation that improved with the alteration of aripiprazole treatment.
Keywords: Amenorrhea, Aripiprazole, Clozapine, Hyperprolactinemia
Psychotropic drugs can lead to hyperprolactinemia due to D2 receptor obstruction in the anterior pituitary gland. As the binding rate of antipsychotic drugs to D2 receptors increases, their effects on the extrapyramidal system and the risk of high prolactin levels increase. Atypical antipsychotics have a lower potency D2 receptor antagonist effect when compared to conventional antipsychotics, and only moderately increase prolactin levels .
Hyperprolactinemia leads to menstrual cycle disorders such as oligomenorrhea and amenorrhea, galactorrhea, gynecomastia, sexual dysfunctions, and acne and hirsutism, weight gain, osteoporosis and mood changes in women. The frequency of endocrinological side effects due to high prolactin levels is 1-10% . The rate of antipsychotic-induced hyperprolactinemia is reported between 60 and 75% in women and 34-43% in men .
It was accepted that clozapine, an atypical antipsychotic, does not increase plasma prolactin levels even at high doses, since it occupies D2 receptors at lower rates. There is no record of clozapine-induced amenorrhea in the literature. In the present case report, we aimed to discuss a schizophrenic patient who developed amenorrhea due to hyperprolactinemia after clozapine treatment and whose clinical manifestation improved with the alteration of aripiprazole treatment.
The initial complaints of a 36-year-old, single, primary school graduate female patient started about 15 years ago as nervousness, aggression, suspiciousness, insomnia, introversion, hearing voices and soliloquy. The patient, diagnosed with schizophrenia during several hospitalizations and regular psychiatric follow-ups, applied to the gynecology and obstetrics outpatient clinic due to amenorrhea. No gynecological organic pathology was determined, additional hormonal treatment was not recommended, and the patient was referred to the psychiatry outpatient clinic. The patient, who had no active psychological complaints and has been using 200 mg/day clozapine regularly for the last six months, had not had a period during the last 3 months. She used olanzapine, risperidone, amisulpride, and quetiapine-based frugs during the inpatient and outpatient periods; however, she benefited significantly from the last clozapine treatment.
In the psychological examination, the patient was determined as conscious, cooperative, oriented, good self-care, with an appearance compatible with her age, and limited eye contact. There were no pathological perception symptoms. Memory and intelligence level were normal. Her affection was obtuse, her associations were regular, abstract thinking skills, ability to evaluate reality, and her attention to detail was full. It was observed that her affection was consistent with her mood, and her mood was depressive. Her speech was slow, and her speech style was normal. Reference ideas were continuous in her thought content. Her sleep was normal. The patient who was without active positive symptoms and with a positive and negative syndrome subscale score of 15 in the Positive and Negative Syndrome Scale (PANSS) and the general psychopathology subscale score of 21, was considered in remission.
She had no history of alcohol or substance use, concomitant organic disease, known drug allergy or drug use. The patient did not have a partner or a regular sex life. She lived alone. In her family, two aunts were diagnosed with bipolar disorder.
General neurological and physical examination findings were normal, and no unusual weight gain or hair growth was observed. She did not have breast fluid discharge, breast tenderness or swelling, and lack of sexual desire complaints. No specificity was found in the complete blood count and routine biochemistry tests requested for the patient. The beta-hcg level was zero and the fasting prolactin level was 70.2µg/L. The patient was referred to our clinic from the obstetrics and gynecology department, after organic pathologies were excluded, and after endocrinology department consultation for possible pituitary pathologies. Since endocrinology did not identify anomalies in other hormone levels in the contrast-enhanced and non-contrast pituitary magnetic resonance imaging (MRI), alteration of the antipsychotic treatment was recommended initially. Hyperprolactinemia due to clozapine administration was considered, and the patient was crossed over from clozapine to aripiprazole.
The clozapine dose of 200 mg/day was gradually decreased and discontinued, aripiprazole 10 mg/day was prescribed, and the dose was gradually increased to 30 mg/day. The patient, whose psychological complaints did not increase during the psychiatry outpatient clinic follow-ups, started to menstruate in the fourth week of aripiprazole treatment. After the regular weekly endocrinology outpatient controls, the patient’s prolactin level was measured as 15.03 µg/L at the fifth week of the new treatment (Figure 1). The patient did not have any psychological or physical complaints during the next three months of the outpatient clinic follow-up, and prolactin levels remained within normal limits. The patient was monitored by the endocrinology department and monthly by the psychiatry outpatient clinic and continued the current treatment.
It is known that atypical antipsychotic drugs increase prolactin levels less than typical antipsychotics . Clozapine is a second-generation antipsychotic with effects on dopamine, serotonin, histamine receptors and muscarinic, glutamatergic and adrenergic receptors. Clozapine is one of the most effective treatment methods for schizophrenia .
Hyperprolactinemia is an adverse effect that could develop during the use of typical and atypical antipsychotics leading to dopaminergic obstruction in the hypothalamic-pituitary-gonadal axis. If hyperprolactinemia is observed, detailed blood tests should be conducted, in addition to anamnesis, physical examination, and a pregnancy test. The presence of complaints such as headache and visual impairment in the history should suggest an intracranial mass. However, the absence of such complaints does not exclude central nervous system pathologies. Thus, the patient should be referred to an endocrinologist for further examination and imaging . Since it is known that the prolactin levels after antipsychotic use are at most 150 ng/ml, this would assist the etiology.
Clozapine is one of the antipsychotic drugs with the lowest accepted risk of hyperprolactinemia in therapeutic doses. It was even observed that clozapine decreased prolactin levels in patients with treatment-induced hyperprolactinemia. However, although the risk of hyperprolactinemia was higher during the periods when our patient took risperidone and amisulpride, hyperprolactinemia-induced amenorrhea was not observed, and the most interesting fact about our case was that amenorrhea was observed after clozapine treatment. This may suggest that hyperprolactinemia in our patient may be observed due to genetic differences in the receptors on which clozapine is effective; however, nothing definitive could be argued since no genetic analysis was conducted.
Although certain studies reported that stable patients with amenorrhea respond better to D2 receptor agonists, the drug treatment was changed in our patient due to the possibility of psychotic exacerbation that may develop with the addition of D2 receptor agonists to the treatment without changing the antipsychotic .
There are case reports and studies which indicated that adding aripiprazole to the treatment in the case of antipsychotic-induced hyperprolactinemia leads to a reduction in prolactin levels . Aripiprazole treatment was attempted in the patient based on the knowledge that aripiprazole reduced the symptomatic hyperprolactinemia effects of other antipsychotic drugs [7,8]. In our case, we supported this knowledge by switching to aripiprazole treatment and observed that the amenorrhea manifestation improved after the switch.
During hyperprolactinemia diagnosis, initially all hyperprolactinemia factors other than antipsychotic treatment should be excluded. Aripiprazole with a partial agonist action mechanism and strong affinity to bind to D2 receptors, could provide an alternative treatment to help reduce hyperprolactinemia . The present case emphasized that the possible side effects of drugs should be questioned regardless of the associated risks. Although it is a rare condition, it should be kept in mind that amenorrhea may develop due to hyperprolactinemia in a group of patients after clozapine initiation. We must remember that sometimes the least expected drugs could cause surprising adverse effects.
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Conflict of interest
1. Kelly DL, Wehring HJ, Earl AK, Sullivan KM, Dickerson FB, Feldman S, et al. Treating symptomatic hyperprolactinemia in women with schizophrenia: presentation of the ongoing DAAMSEL clinical trial (Dopamine partial Agonist, Aripiprazole, for the Management of Symptomatic Elevated prolactin). BMC Psychiatry. 2013; 13(1):1-14.
2. Torre D, Falorni A. Pharmacological causes of hyperprolactinemia. Ther Clin Risk Manag. 2007; 3(5):929-51.
3. Kinon BJ, Gilmore JA, Liu H, Halbreich UM. Prevalence of hyperprolactinemia in schizophrenic patients treated with conventional antipsychotic medications or risperidone. Psychoneuroendocrinology. 2003; 28(Suppl. 2):55-68.
4. Windgassen KW, Wesselmann U, Mönking H. Galactorrhea and hyperprolactinemia in schizophrenicpatients on neuroleptics: frequencyandetiology. Neuropsychobiology. 1996; 33(3):142-6.
5. Tollin SR. Use of the dopamine agonists bromocriptine and cabergoline in the management of risperidone-induced hyperprolactinemia in patients with psychotic disorders. J Endocrinol Invest. 2000; 23(11):765-70.
6. Yeager A, Shad MU. Aripiprazole for the Management of Antipsychotic-Induced Hyperprolactinemia A Retrospective Case Series. Prim Care Companion CNS Disord. 2020; 22(1). DOI: 10.4088/PCC.19br02536.
7. Kane JM, Meltzer HY, Carson WH, McQuade RD, Marcus RN, Sanchez R. Aripiprazole for treatment-resistant schizophrenia: Results of a multicenter, randomized, double-blind, comparison study versus perphenazine. J Clin Psychiatry. 2007; 68(2):213–23.
8. Saitis M, Papazisis G, Katsigiannopoulos K, Kouvelas D. Aripiprazole resolves amisulpride and ziprasidone induced hyperprolactinemia. Psychiatry Clin Neurosci. 2008; 62(5):624.
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Aslı Kazğan, Sevler Yıldız. An unexpected circumstance; clozapine-induced amenorrhea: A case report. Ann Clin Anal Med 2022;13(Suppl 1): S36-38
A rare complication of inguinal hernia surgery: Iliopsoas hematoma
Murat Kartal, Tolga Kalaycı
Department of General Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
DOI: 10.4328/ACAM.20758 Received: 2021-06-23 Accepted: 2021-08-19 Published Online: 2022-01-07 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S39-41
Corresponding Author: Murat Kartal, Erzurum Regional Education and Research Hospital, Erzurum, Turkey. E-mail: email@example.com P: +90 507 191 96 09 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1396-5365
This case report presents an iliopsoas hematoma that developed after elective inguinal hernia surgery with the aim of evaluating the diagnosis and treatment process of the patient. A 75-year-old man underwent left inguinal hernia surgery. At the ninth hour after surgery, his blood pressure was 78/48 mmHg and his heartbeat was 135 beats/min. A left iliopsoas hematoma approximately 150 mm wide was seen by computed tomography. Monitoring of vital signs and fluid replacement were begun in the intensive care unit. As the patient’s hemoglobin level was 5.8 g/dL, two units of erythrocyte suspension were administered. He was discharged after his hemoglobin level increased to 9.6 g/dL and his vital signs were stable on the seventh postoperative day.
Keywords: Iliopsoas hematoma, hemodynamic shock, inguinal hernia surgery, Lichtenstein repair, conservative treatment.
Inguinal hernia repair is an extremely common operation performed by general surgeons. Nearly 800,000 inguinal hernia repairs are performed each year in the United States. The purpose of inguinal hernia repair is to close the hernia defect and provide tension-free repair. These aims can be met with either open surgery or laparoscopic surgery. Prosthetic material is used for tension-free hernia repair. On the other hand, in cases where mesh cannot be used, it is appropriate to perform a tension-free repair with suture materials .
Inguinal hernias are divided into three categories as direct, indirect, and femoral hernias according to where they originate. Patients present with bulging and pain in the inguinal area. Diagnosis of inguinal hernia is primarily made by clinical examination, and superficial ultrasonography (USG) is also helpful in diagnosis. Surgical repair is recommended for all symptomatic inguinal hernias to prevent possible complications such as hematoma, seroma, and scrotal complications.
The rate of hematoma after inguinal hernia surgery varies between 5.6% and 16% . Localized hematomas may occur in the ilioinguinal region, or they may be large enough in size to fill the retroperitoneal and scrotal area and require reoperation. It is important to make a timely surgical decision based on clinical findings of large hematomas.
This case report presents the case of a 75-year-old man who developed an iliopsoas hematoma that was treated conservatively after a left inguinal hernia with Lichtenstein inguinal hernia repair.
A 75-year-old man with a history of hypertension was admitted to Department of General Surgery of Erzurum Regional Education and Research Hospital in May 2021 with left groin pain and bulging for five years. The patient had no history of surgery or anticoagulant therapy use. On evaluation, his vital findings were as follows: blood pressure, 135/82 mmHg; pulse rate, 84 beats/min (bpm); respiratory rate, 16 breaths/min; temperature, 37.0 °C; oxygen saturation on room air, 95%-97%.
Upon physical examination of both inguinal regions, there was only a left-side inguinal hernia without scrotal pathology. The contralateral inguinal side had no pathology. In addition, abdominal physical examination was benign. The results of laboratory tests were unremarkable before surgery (hemoglobin: 12.4 g/dL). After all operative preparations, the patient underwent elective inguinal hernia operation. Upon exploration, he was diagnosed with a 3B hernia according to the Nyhus classification (Table 1). Lichtenstein inguinal hernia repair was performed. A drainage catheter was inserted into the operation area. After the operation, he was admitted for follow-up in the service.
At the ninth hour of the patient’s follow-up, his blood pressure was 78/48 mmHg and his heart rate was 135 bpm. An abdominal exam and inguinal area exam both revealed no pathology. At that point, his hemoglobin level had decreased to 5.8 g/dL. There was no discharge from the drainage catheter and there was no sign of intraabdominal hemorrhage by bedside USG. A computed tomography (CT) scan of the abdomen and pelvis showed a left iliopsoas hematoma approximately 150 mm wide without contrast extravasation (Figure 1 and Figure 2).
The patient was admitted to the intensive care unit for follow-up. Fluid replacement and monitoring of vital signs were begun. As the patient’s hemoglobin was 5.8 g/dL, two units of erythrocyte suspension were administered. Abdominal and inguinal region examinations were performed daily.
On the seventh day after admission, the patient was discharged because his hemoglobin level of 9.6 g/dL had not decreased again and his vital signs were stable. From the moment of diagnosis to discharge, the patient required no surgical or interventional procedures.
Bleeding complications may occur during or after inguinal hernia repair surgeries. The rate of hematoma after inguinal hernia surgery varies between 5.6% and 16% . Hematoma may develop after both non-mesh repairs and mesh repairs in inguinal hernia operations. These hematomas are mostly detected in the inguinal region or the scrotum. However, in the English-language literature, some case reports have presented iliopsoas hematomas after inguinal hernia operations. Although hemophilia, anticoagulant use, and trauma are among the main causes, such hematomas develop spontaneously in many cases and no etiology can be identified . As in our case, early detection of the hematoma is life-saving. Fatal outcomes can occur in delayed or misdiagnosed cases.
Iliopsoas hematoma is a rare condition that is difficult to treat. Depending on the amount of bleeding, it may present with abdominal bloating and pain, findings due to femoral nerve compression, or hemorrhagic shock with severe hypotension and tachycardia . In doubtful cases, abdominal USG is the first examination to be performed as a cheap, easily accessible, and non-invasive method allowing for quick preliminary evaluations. In the presence of suspicious appearance of hematoma on USG, abdominal CT is a specific imaging method to confirm the diagnosis . Contrast-enhanced abdominal and pelvic CT provides information about contrast extravasation and all intraabdominal structures. However, in cases in which contrast is contraindicated, non-contrast CT is also helpful. In our case, iliopsoas hematoma manifested itself with hemorrhagic shock findings in a patient who had no history of anticoagulant use, and the diagnosis was confirmed by abdominal CT.
There are different treatment methods for iliopsoas hematoma, including conservative treatment, embolization, and surgery. Conservative treatment is the first treatment method preferred as a precaution against the additional risks of surgery. The vital signs of the patient should be checked closely. In addition, it is important to stop the use of blood thinners immediately. Both the abdomen and the inguinal region should be examined each day and the hemoglobin levels of the patient should be checked frequently (every six hours in the immediate days after the diagnosis of iliopsoas hematoma). If patients have hemoglobin levels below 7 g/dL, the aim should be to increase the value above that level if possible and maintain it. The need for erythrocyte suspension should be evaluated according to the hemoglobin level . Although there were signs of hemorrhagic shock in our case, since there were no neurological findings, conservative treatment was applied in the first step and the patient’s bleeding was controlled without the need for surgical intervention.
Embolization may be used in selected cases, requiring specialty treatment . Embolization may be useful for hemodynamically stable patients with persistent bleeding. However, in complicated and unstable cases, and in cases in which neurological symptoms develop due to hemorrhagic shock, surgical treatment should be considered first. The main purpose of hematoma surgery is to ligate the actively bleeding vessel.
In conclusion, iliopsoas hematoma after inguinal hernia surgery is a rare complication. It can be seen after open surgery or laparoscopic surgery. Iliopsoas hematoma should be kept in mind in cases of unexplained hypotension, especially in the postoperative period without ecchymosis or swelling in the scrotum or incision line. After ensuring the hemodynamic stability of the patient, imaging modalities such as USG and CT are helpful in diagnosis. After the diagnosis of iliopsoas hematoma is confirmed, conservative treatment, embolization, or surgery should be planned according to the patient’s hemodynamic status. The most important factor to be considered is early diagnosis of the hematoma. If the diagnosis of iliopsoas hematoma is delayed or missed, life-threatening complications may ensue.
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1. Li J, Gong W, Liu Q. Intraoperative adjunctive techniques to reduce seroma formation in laparoscopic inguinal hernioplasty: a systematic review. Hernia. 2019;23(4):723-31.
2. Schmedt C, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surgical Endoscopy and Other Interventional Techniques. 2005;19(2):188-99.
3. Bittner R, Sauerland S, Schmedt C-G. Comparison of endoscopic techniques vs Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surgical Endoscopy And Other Interventional Techniques. 2005;19(5):605-15.
4. Zago G, Appel-da-Silva MC, Danzmann LC. Iliopsoas muscle hematoma during treatment with warfarin. Arq Bras Cardiol. 2010;94(1):e1-3.
5. Sugiyama C, Akai A, Yamakita N, Ikeda T, Yasuda K. Muscle hematoma: a critically important complication of alcoholic liver cirrhosis. World Journal of Gastroenterology: WJG. 2009;15(35):4457.
6. Marquardt G, Angles SB, Leheta F, Seifert V. Spontaneous haematoma of the iliac psoas muscle: a case report and review of the literature. Archives of orthopaedic and trauma surgery. 2002;122(2):109-11.
7. Kalayci T. Rectus Sheath Hematoma Due to Low Molecular Weight Heparin in a COVID-19 Patient in Turkey. Cureus. 2021;13(5).
8. Parmer SS, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral neuropathy following retroperitoneal hemorrhage: case series and review of the literature. Annals of vascular surgery. 2006;20(4):536-40.
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Murat Kartal, Tolga Kalaycı. A rare complication of inguinal hernia surgery: Iliopsoas hematoma. Ann Clin Anal Med 2022;13(Suppl 1): S39-41
Physiotherapy results of a patient with critical illness polyneuropathy due to COVID-19: A case report
Güzin Kara, Emre Baskan, Aziz Dengiz
Department of Physical Therapy and Rehabilitation, Pamukkale University, Denizli, Turkey
DOI: 10.4328/ACAM.20811 Received: 2021-08-09 Accepted: 2021-09-15 Published Online: 2021-09-16 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S42-45
Corresponding Author: Güzin Kara, Department of Physical Therapy and Rehabilitation, Pamukkale University, Kınıklı Campus, 20070, Denizli, Turkey. E-mail: firstname.lastname@example.org / email@example.com P: +90 258 296 42 85 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8893-5235
The aim of this study is to examine the results of physiotherapy in a patient with critical illness polyneuropathy (CIP) due to coronavirus disease 2019 (COVID-19). The 48-year-old male patient with CIP due to COVID-19 was enrolled in a physiotherapy program for 3 months with 5 sessions/week. Pain intensity, motor skills, daily living activities, fatigue level, cognitive status, and decubitus ulcer were evaluated with a visual analogue scale, the Medical Research Council-Sum Score, the Functional Independence Scale, the Fatigue Severity Scale, the Standardized Mini-Mental Test, and pressure wound staging, respectively. Positive improvements were achieved in functional level, fatigue, pain, and pressure sores with the physiotherapy program for this patient with CIP due to COVID-19. This report provides an idea about the effects of physiotherapy programs for COVID-19-related CIP to academics and clinicians working in this field.
Keywords: COVID-19, Polyneuropathy, Neurological Physiotherapy, Critical Illness, Case Reports
Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly recognized as a major complication with potential long-term consequences for both patients and the healthcare system. One study reported that approximately 36% of confirmed coronavirus disease 2019 (COVID-19) cases involved neurological symptoms. Patients with severe COVID-19 infections are at risk of developing neurological diseases such as stroke, multiple sclerosis, polyneuropathy, and encephalitis .
COVID-19-related polyneuropathy, also called critical illness polyneuropathy (CIP), is characterized by bilateral muscle weakness, sensory impairment, and decreased deep tendon reflexes. Nerve conduction studies have also indicated temporarily reduced compound muscle action potential amplitudes, prolonged distal motor latency, conduction block, or temporal dispersion in patients with CIP .
Physical therapy approaches are important in terms of reducing the respiratory problems, addressing the effects of extended immobilization, and treating the neurological complications that may occur during and after COVID-19. The present report is important in terms of sharing the symptoms and physiotherapy results of a patient who developed polyneuropathy related to COVID-19 with clinicians and academics interested in this field. The aim of this paper is to examine the symptoms and physiotherapy results of this case of polyneuropathy due to COVID-19.
A 48-year-old male patient with CIP due to COVID-19 is presented in this study. The patient was enrolled in the physiotherapy and rehabilitation program of the Pamukkale University Neurological Rehabilitation Unit between May and August 2020. He was informed about the case report verbally and in writing and he provided informed consent.
The patient was evaluated before the rehabilitation program and at 1 month and 3 months after the first evaluation. The type of pain, use of analgesics, and localization were recorded. The severity of pain was determined with a visual analogue scale (VAS). Deep tendon reflexes and muscle tone were evaluated. The Medical Research Council-Sum Score (MRC-SS) was used to assess motor skills, the Functional Independence Measure (FIM) was used for daily living activities, the Fatigue Severity Scale (FSS) was used for fatigue level, and the Standardized Mini-Mental Test (SMMT) was used for cognitive status. A decubitus ulcer in the sacral region was assessed by pressure wound staging. Electromyography (EMG) findings for the diagnosis of CIP were recorded.
The VAS allows for a subjective assessment of pain. The patient marked the severity of his pain on a 10-cm VAS. The scale was scored between 0 and 10, from 0 = no pain to 10 = worst pain.
The MRC-SS is a motor evaluation used in cases of polyneuropathies and muscular dystrophies. Six muscle groups were evaluated bilaterally, including shoulder abductors, elbow flexors, wrist extensors, hip flexors, knee extensors, and ankle dorsiflexors. Each muscle group was assessed from 0 = paralysis to 5 = normal strength .
The FIM consists of six parts that measure physical and cognitive inadequacies, need for help, and care burden in daily living activities. These six parts include the functions of self-care, sphincter control, mobility, movement, communication, and social cognition, with a total of 18 items. Each item is assessed on a 7-point Likert scale that indicates the amount of assistance required (1 = total assistance, 7 = total independence) .
The FSS is a 9-item scale that measures the severity of fatigue and its effects on daily living activities from the patient’s own perspective. Each item of the scale is scored between 0 and 7 (0 = strongly disagree, 7 = strongly agree). The total score is calculated by dividing the score by 7 .
The SMMT includes the five main domains of orientation (10 points), registration (3 points), attention (5 points), recall (3 points), and language (9 points). It contains 11 items. The total score range is 0-30 points. Cut-off scores are considered as follows: 27-30: within normal limits; 24-27: mild cognitive impairment; fewer than 24 points: severe cognitive impairment .
The Classification of Pressure Ulcers is one of the most commonly used standardized classification systems for pressure injuries and is recommended by the National Pressure Ulcers Panel . It consists of 4 stages. In stage 1, there is a rash that does not fade on the skin, while the integrity of the skin is preserved. In stage 4, full-thickness skin loss with advanced tissue damage and necrosis indicates the destruction of muscle, bone, or connective tissues.
The physiotherapy and rehabilitation program was applied for the patient for 3 months, with sessions conducted 5 days/week and 1 hour/day. The rehabilitation program included calisthenic exercises, strengthening exercises, sensory training, proprioceptive neuromuscular facilitation techniques, breathing exercises, gait training, wrist stabilization, and grip-release training. A static hand-wrist splint and a bilateral foot-ankle splint were also recommended. The patient used his orthoses at night and rest. A dorsiflexion band was recommended bilaterally for ambulation. The use and care of the orthoses were taught to both the patient and his wife. The rehabilitation program was also taught to the patient and his wife before he was discharged.
The patient had been diagnosed with COVID-19 on March 15, 2020. After 3 days of follow-up in the service, he was moved to the intensive care unit on March 18, 2020 and intubated. He was returned to the service from the intensive care unit on May 29, 2020. The bilateral sural nerve, right tibial motor nerve, and left fibular motor nerve could not be stimulated in the EMG evaluation performed on June 2, 2020. The right ulnar motor nerve compound muscle action potential amplitude was low. As a result, the data were compatible with sensorimotor polyneuropathy. The patient was enrolled in the rehabilitation program between May and August 2020.
He had no history of chronic disease or smoking. He had a stage 4 decubitus ulcer in the sacral region 5 × 7 cm in size according to the Classification of Pressure Ulcers before treatment. After treatment, the decubitus ulcer was evaluated as stage 3 and 3 × 4 cm. The severity of shoulder pain had decreased in both rest and activity at the end of the rehabilitation program (Table 1).
The biceps, triceps, styloradial, patellar, and Achilles reflexes decreased bilaterally. The patient had a right-handed drop hand and bilateral drop foot before treatment. At the end of the treatment, it was determined that there was an increase in the tone of the right wrist and finger extensor muscle groups and the bilateral M. tibialis anterior muscles. In addition, the strength of the affected muscles increased after treatment (Table 2).
While the patient was bedridden before treatment, he began to walk using a walker after treatment. His level of participation in daily living activities increased after treatment. A decrease in fatigue and an increase in cognitive abilities were also observed (Table 2).
The world is still currently experiencing a pandemic of an infectious disease called COVID-19. Turkey, like all countries, has been seriously affected by the pandemic.
Cases of polyneuropathy originating from COVID-19 have been reported in the literature. We analyzed the results of a physiotherapy and rehabilitation program for our patient with CIP due to COVID-19. At the end of the 3-month follow-up, significant improvements were found in the pain, cognition, fatigue, and functional outcomes of this case.
In the literature, back and waist pains are particularly reported among COVID-19 patients . Pain was detected in both shoulders in our patient, interestingly. Furthermore, the effects of the shoulder pain continued even though it decreased for up to 3 months. The VAS scores before therapy and 1 month after physical therapy decreased with medical treatment. In the evaluation at 3 months, the decrease in pain values was maintained despite the discontinuation of medication.
In the motor evaluation of the patient, muscle strength was found to have been severely affected after COVID-19. In the initial EMG values, the bilateral sural nerve, right tibial nerve, and left fibular nerve activation were lost or decreased. After 3 months of follow-up, the muscle strength of the deltoid, iliopsoas, and quadriceps femoris muscles had increased. The improvements in wrist extension and foot dorsiflexion were not at a functional level, although there was a slight increase. The literature supports increased distal involvement due to CIP in COVID-19.
Increased patient independence resulted in a significant reduction in the level of fatigue through the recovery of functions. There was a slight difference between the cognitive status results of the first month and the third month, but that value could not be measured in the intensive care unit. None of these findings were statistically significant.
The symptoms that can be seen in humans after COVID-19 and their progress are still not fully understood. We have tried to shed light on this situation by presenting a polyneuropathy condition caused by COVID-19 with routine physical therapy procedures. We encountered a situation in terms of progression similar to that generally presented in the literature. The rehabilitation of our patient is still continuing and his functional development is ongoing. Long-term follow-up results in cases of polyneuropathy due to COVID-19 will be valuable in terms of contributing to the literature. Continuing distal involvement in the patient presented here supports the finding of axonal degeneration. For all these reasons, the severity and progression of neuropathic involvement due to COVID-19 warrants further exploration. The present case report has contributed to the literature on this subject accordingly.
The authors would like to thank the participant for his support.
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Conflict of interest
1. Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A, et al. Neurological associations of COVID-19. Lancet Neurol. 2020;19(9):767-83.
2. Montalvan V, Lee J, Bueso T, de Toledo J, Rivas K. Neurological manifestations of COVID-19 and other coronavirus infections: a systematic review. Clin Neurol Neurosurg. 2020;194:105921.
3. Kleyweg RP, Van Der Meché FGA, Schmitz PIM. Interobserver agreement in the assessment of muscle strength and functional abilities in Guillain-Barré syndrome. Muscle Nerve. 1991;14(11):1103-9.
4. Renate V, Krumm B, Schweisthal B. Functional independence measure (FIM) assessing outcome in medical rehabilitation of neurologically ill adolescents. Int J Rehabil Res. 2001;24(2):123-31.
5. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46(10):1121-3.
6. Güngen C, Ertan T, Eker E, Yaşar R, Engin F. Standardize mini mental test’in Türk toplumunda hafif demans tanısında geçerlik ve güvenilirliği. Turk Psikiyatri Derg. 2002;13(4):273-81.Turkish.
7. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014
8. Cofano F, Tartara F, Zenga F, Penner F, Lanotte M, Garbossa D. Back pain and accesses to Emergency Departments during COVID-19 lockdown in Italy. Neurosurgery. 2020;87(2):E211-E211.
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Güzin Kara, Emre Baskan, Aziz Dengiz. Physiotherapy results of a patient with critical illness polyneuropathy due to COVID-19: A case report. Ann Clin Anal Med 2022;13(Suppl 1): S42-45
A novel RYR1 sequence variant in central core disease: A case report
Department of Physical Therapy and Rehabilitation, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
DOI: 10.4328/ACAM.20875 Received: 2021-09-28 Accepted: 2021-10-27 Published Online: 2021-11-02 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S46-48
Corresponding Author: Askeri Türken, Gazi Yaşargil Training and Research Hospital, Division of Physical Therapy and Rehabilitation, Diyarbakır, Turkey. E-mail: firstname.lastname@example.org P: +90 532 776 12 40 / +90 412 258 00 60 F: +90 412 258 00 50 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0638-8918
Muscular dystrophies are inherited diseases that cause progressive muscular weakness. Dystrophies are diagnosed with a biopsy, which histologically shows fiber size, areas of muscle necrosis, amounts of fat and connective tissue, however, genetic screening is definitive for the diagnosis of disease. Congenital myopathies are neuromuscular disorders that affect skeletal muscles used for movement. Muscles are relaxed by repeated contractions. In this case, a patient with central core disease is presented with novel alteration in the ryanodine receptor 1(RYR1) gene after a 24-year delayed diagnosis. The mutation seen in our case occurred in the central region and caused central core disease. In conclusion, in the diseases, differential diagnosis should be considered a transition to a correct diagnosis, as they can imitate each other in cases such as complaints, laboratory and imaging.
Keywords: Muscular Dystrophy, Myopathy, Myotonia, Muscular Weakness, Ryanodine Receptor 1Gene
Central core disease (CCD) is a non-progressive, infrequent, congenital myopathy that causes weakness in the proximal muscles, which are closest to the center of the body, such as the muscles of the legs, upper arms, shoulder and pelvis . Symptoms are generally observed during infancy, but may appear at any age. It clinically presents with mild hypotonia during early childhood, delayed motor skills, muscle weakness and gracility, frequent spinal deformities, skeletal malformations such as scoliosis and hip dislocation . The clinical features of patient were consistent with the diagnostic features of the CCD. CCD is also allelic to malignant hyperthermia (MH) susceptibility .
A 42-year-old female patient was admitted to the hospital with complaints of fainting and general muscle weakness during a sports competition. Less exercise was recommended considering fibromyalgia. Until the age of 42, when she came to the clinic, she was diagnosed in different departments with fibromyalgia, depression, rheumatoid arthritis, ankylosing spondylitis, polymyositis, epilepsy and multiple sclerosis. At the start of drug therapy for each diagnosis, the drugs were stopped when the patient’s complaints increased. At the time of examination, her blood tests, Electromyography (EMG), and muscular biopsy results were normal. Demyelinating plaques were seen on brain and cervical mangnetic resonance imaging (MRI). In the cerebrospinal fluid analysis, the third oligoclonal band was positive. The patient was diagnosed with multiple sclerosis (MS). Despite MS treatment, the patient’s complaints never stopped and even increased. At her next visit, her creatine kinase, alanine aminotransferase (ALT), and aspartate aminotranferase (AST) enzymes were high, therefore the patient stopped taking MS treatment. In May 2019, the patient applied to the physical therapy and rehabilitation outpatient clinic with a complaint of pain in her right arm. In clinic examination, the general condition was good, the posture was normal, the arms were symmetrical when walking. There was mild weakness and rubbing in her right arm, and pallor of the skeletal muscles. Speech, swallowing and hearing were normal. Muscle Strength Rating Scale according to Oxford Scale Proximal muscle values were 4+/5. Mild myotonia was observed in the fingers, similar to spasticity, but not matching the definition of spasticity. Range of motion and superficial deep senses were normal. Bilateral Achilles reflexes were decreased. There was no pathological reflex. She had a clinic that had symptoms of the current diagnoses, but did not fit a differential diagnosis. Myopathy was suspected, and the patient was sent for gene analysis. Molecular analysis of the RYR1 gene revealed a Gly2394Ser mutation in exon 44, and this mutation has not been previously described in the literature. After the patient’s history, physical and neurological evaluation, a gene analysis was requested, considering that it was not compatible with the diagnosis of MS, although MRI supported it, and it was more compatible with myopathy. As a result, the definitive diagnosis was CCD. A combined program of posture rehabilitation, balance-coordination and strengthening exercises was applied before and after the FAC and BI measurements. Pre-treatment: Functional Ambulation Classification (FAC): 4, Post-treatment FAC: 5, Pre-treatment Barthel activities of daily living index score (BI): 90; Post-treatment BI: 100.
In this study, the informed voluntary consent form was taken from the patient for this case report.
CCD is a slowly or non-progressive weakness congenital myopathy disease, characterized by hypotonia and delay in motor development in childhood [1,4]. It is autosomal dominantly-recessively inherited and has a frequency of 5-6: 100,000. CCD starts with weakness in the proximal muscles, especially in the lower proximal extremities and symmetrically affects both sides of the body.
Although CCD is associated with malignant hyperthermia, muscle biopsies may be normal in some patients . In general, the N-terminal and central regions are responsible for malignant hyperthermia.
The patient’s muscle biopsy, serum creatine phosphokinase level and EMG were normal. Magnetic resonance index (MRI) and cerebrospinal fluid (CSF) culture results were in favor of multiple sclerosis.The longest diagnosis period was MS for 24 years, and she received many treatments but her complaints did not improve, while CCD disease is caused by mutations in the C-terminal region [6,7]. In our case, c.7180A> G, corresponding to the p.Gly2394Ser mutation in the central region of the 44th exon of RYR1 gene caused the CCD disease.
Although there is no definitive treatment for core myopathies, supportive treatment is recommended. Rehabilitation is still the best treatment. Pain due to myotonia has been reported to be common . In the examinations of the patient, the intense myotonic state due to myopathy was defined as spasticity that can develop in MS without considering the differential diagnosis. After the final diagnosis, the patient was prescribed carbamazepine up to 400 mg/day and 30 sessions of active rehabilitation program, the patient was given weight-free atrophy and correction of myotonic complaints in the presence of a physiotherapist, 1 session for1 hour per day, taking into account the patient’s compliance, participation and fatigue.
The mutation seen in our case occurred in the central region and caused CCD disease. This mutation is novel (p.Gly2394Ser in the 44th exon of RYR1 gene) in the literature. Central region mutations can also cause CCD disease.
In conclusion, in the diseases, differential diagnosis should be considered as a transition to the correct diagnosis, as they can imitate each other in cases such as complaints, laboratory and imaging.
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Conflict of interest
1. Magee KR, Shy GM. A new congenital non-progressive myopathy. Brain. 1956;79(4):610-21.
2. Shuaib A, Paasuke RT, Brownell KW. Central core disease. Clinical features in 13 patients. Medicine (Baltimore). 1987;66:389-96.
3. Solbakken G, Løseth S, Froholdt A, Eikeland TD, Nærland T, Frich JC, et al. Pain in adult myotonic dystrophy type 1: relation to function and gender. BMC. 2021; (1): 1-11.
4. Dubowitz, Victor. Muscle disorders in childhood. 2nd ed. London: Bailliere Tindall Limited; 1995.
5. McCarthy TV, Quane KA, Lynch PJ. Ryanodine receptor mutations in malignant hyperthermia and central core disease. Hum Mutat. 2000; 15(5):410-17.
6. Jungbluth H. Central core disease. Orphanet J Rare Dis. 2007; 2(1):1-9.
7. Amburgey K, Bailey A, Hwang JH, Tarnopolsky MA, Bonnemann CG, Medne L, et al. Genotype phenotype correlations in recessive RYR1-related myopathies. Orphanet J Rare Dis. 2013; 8 (1):1-12.
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Askeri Türken. A novel RYR1 sequence variant in central core disease: A case report. Ann Clin Anal Med 2022;13(Suppl 1): S46-48
A rare cause of severe ecchymosis: ‘Diamond-Gardner syndrome’
Hakan Kocoglu, Faruk Karandere, Emine Uzun, Dogancan Akyurek, Betul Erismis, Abdulbaki Kumbasar
Department of Internal Medicine, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.20891 Received: 2021-10-09 Accepted: 2021-11-02 Published Online: 2021-11-03 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S49-52
Corresponding Author: Betul Erismis, Zuhuratbaba Mah, Dr. Tevfik Sağlam Cd., No:11, 34147, Department of Internal Medicine, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey. E-mail: email@example.com Corresponding Author ORCID ID: https://orcid.org/0000-0003-2970-2076
Diamond-Gardner Syndrome (DGS) is an autoimmune disease characterized by painful ecchymoses that develop following emotional stress or trauma and is extremely rare. The underlying mechanisms of this disease are still unknown. The majority of cases were reported in women aged 19-72 and only 5% of them were in males. Here, in this case, we present a 45-year-old male patient with bipolar mood disorder and paranoid schizophrenia who was diagnosed with DGS due to severe ecchymoses in both legs and who was successfully treated with escitalopram, cetirizine, vitamin C, and prednisolone as well as psychotherapy.
Keywords: Diamond-Gardner Syndrome, Autoerythrocyte Sensitization Syndrome, Ecchymoses
Autoerythrocyte sensitization syndrome, also known as psychogenic purpura or Diamond- Gardner Syndrome (DGS), was first described in 1955 in four women patients who had repetitive painful ecchymosis followed by emotional or physical stress .
In the following years, after this syndrome became known, cases were rarely reported. While adult females were mostly reported, but there are also cases in adult men and children [2,3]. Patients with DGS experience spontaneous, repetitive, painful ecchymosis after a prodrome of itching and/or pain in the skin of the arms, legs, trunk and/or face. It is mainly diagnosed in women, under the age of 30 years, with emotional stress or one or more concomitant mental illnesses. Although some theories have been suggested, the underlying mechanisms of this disease are unknown.
Here, in this case, we present a 45-year-old male patient with bipolar mood disorder and paranoid schizophrenia who was diagnosed with DGS due to severe ecchymoses in both legs and who was successfully treated with escitalopram, cetirizine, vitamin C, and prednisolone as well as psychotherapy.
A 45-year-old male patient hospitalized in the forensic psychiatry clinic of a psychiatric hospital with the diagnoses of paranoid schizophrenia for 3 years and bipolar affective disorder for 12 years was transferred to our clinic in January 2021 due to progressively increasing, painful, widespread erythema and ecchymoses on his legs (Figure 1). The patient needed occasional blood transfusions due to droops in hematocrit levels, and initial investigative studies were negative in related hospital.
At the time of admission, the patient was taking biperiden 2 mg, quetiapine 100 mg, risperidone 3 mg, and amisulpride 400 mg. Her family history was unremarkable for bleeding disorders. There was no history of trauma or prodromal symptoms. He did not have a history of abnormal bleeding or easy bruising, hematuria or dysuria.
On physical examination, there was no pathological findings except for lower extremity ecchymoses. No pathological findings were found in peripheral blood smear and bone marrow aspiration and biopsy. Munchausen’s syndrome, dermatitis artefacta, and nonaccidental trauma were considered and ruled out after careful questioning and observation.
In laboratory examination, erythrocyte sedimentation rate is 20 mm/hr and complete blood count, international normalized ratio, partial thromboplastin time, fibrinogen and liver function tests, platelet aggregation studies, protein C and S, von Willebrand factor, ristocetin cofactor assay, antithrombin III, cryoglobulin, haptoglobin, B12 and folate vitamins, iron and ferritin levels, rheumatoid factor, C-reactive protein, protein electrophoresis, immunoglobulin and complement levels were normal and direct and indirect coombs tests, antineutrophil cytoplasmic antibodies, lupus anticoagulant, anti-double-stranded DNA were negative. Gastroscopy and colonoscopy were performed and did not show any pathological findings. Examination of doppler ultrasonography of the lower extremity arteries and veins was normal. Skin biopsy of ecchymosis showed thinning of the epidermis, prominent extravasated erythrocytes in the dermis, vascular proliferation, thick-walled vascular structure in the subcutaneous fatty tissue. There was no evidence of vasculitis, and immunofluorescence studies were negative.
In view of the negative results of the performed studies and the existence of erythrocyte extravasation in the skin biopsy, without any evidence of vasculitis or panniculitis, DGS was considered as a diagnostic possibility. To strengthen the diagnosis of DGS, an intradermal sensitization test with autologous erythrocytes was performed. Autologous erythrocytes (0.1 ml) was injected intradermally in the right forearm inner face and 0.1 ml of 0.9% saline solution was injected intradermally as a control in the right forearm outer face (Figures 2). At the end of the 24-hour follow-up, painful ecchymosis was detected in the test area whereas the test was negative in the control area.
Based on the above findings, a final diagnosis of DGS was made, and 10 mg of escitalopram, 10 mg of cetirizine, vitamin C, 40 mg of prednisolone were started. Although there was a decrease in the patient’s ecchymoses and decrease in the drop of hematocrit value in the 2nd week of treatment, the patient still needed erythrocyte transfusion at intervals. The patient was transferred back to the psychiatric hospital where he was previously hospitalized, and psychotherapy was started. In the 2nd week after psychotherapy, the patient’s ecchymoses regressed significantly, there was no decrease in hematocrit values and there was no need for transfusion (Figure 3).
DGS is an extremely rare disorder, and only about 200 cases have been reported in the literature until the year 2015 . The majority of cases are reported in women ages 19-72, and only 5% of them are of the male gender [5,6]. When we reviewed the literature, we found that it was the first case with such severe ecchymoses in a male patient with DGS.
The etiological mechanism leading to the disease is not known exactly, and it is thought that severe stress or emotional trauma triggers the disease. Many psychiatric disorders such as mood disorder, anxiety and personality disorders, somatoform and dissociative disorders can be seen. In our case, our patient had bipolar affective disorder for 12 years and was hospitalized in the forensic psychiatry clinic with the diagnosis of paranoid schizophrenia for 3 years .
There is no pathognomonic test for DGS, but intradermal skin testing may be useful in diagnosis. The most used method is intradermal injection of 0.1 ml of autologous venous blood. Ecchymosis with autologous venous blood was also observed in our case. Although a positive test reaction is helpful in making the diagnosis, a negative test does not rule out typical-appearing DGS [8,9].
The diagnosis of DGS depends on the exclusion of other causes of ecchymosis and purpura since there is no definitive confirmatory laboratory test. Hemostatic disorders such as von Willebrand disease, quantitative and qualitative platelet disorders, coagulation factor deficiencies, antiphospholipid syndrome, systemic lupus erythematosus, vasculitis, erythema nodosum, vascular bleeding disorders (Hereditary Hemorrhagic Telangiectasia, Ehlers-Danlos Syndrome), Pfeifer-Weber-Christian disease, Henoch-Schönlein purpura and other rheumatological conditions should be excluded. Skin biopsies may be useful to help rule out spontaneous panniculitis and vasculitis. Finally, the possibilities of artificial purpura such as Munchausen syndrome, dermatitis artefacta should also be considered [10-13].
Treatments such as antihistamines, corticosteroids, beta-blockers, bioflavonoids, calcium channel blockers, albumin infusion, immunosuppressive therapy, plasmapheresis, intravenous immunoglobulin, anticoagulants, antidepressants, hormones and vitamin C were tried in the treatment, but they were not found to be very effective. Psychological treatment seems to be most effective treatment in these patients, and in our case, some response was obtained with vitamin C, cetirizine, and steroids, but it was observed that the lesions completely regressed with only psychotherapy [13-15].
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1. Gardner FH, Diamond LK. Autoerythrocyte sensitization; a form of purpura producing painful bruising following autosensitization to red blood cells in certain women. Blood. 1955;10(7):675-90.
2. Ingber A, Alcalay J, Feuerman EJ. Autoerythrocyte sensitization (Gardner-Diamond syndrome) in men: a case report and review of the literature. Postgrad Med J. 1985;61(719):823-6.
3. Okur M, Turan H, Ozkan A, Güneş C, Kocabay K. An extremely rare cause of bruising in children: autoerythrocyte sensitization syndrome. Turk J Haematol. 2012;29(2):201-3.
4. Jafferany M, Bhattacharya G. Psychogenic Purpura (Gardner-Diamond Syndrome). Prim Care Companion CNS Disord. 2015;17(1):10.
5. Silny W, Marciniak A, Czarnecka-Operacz M, Zaba R, Schwartz RA. Gardner-Diamond syndrome. Int J Dermatol. 2010;49(10):1178-81.
6. Sawant NS, Singh DA. Antidepressant-induced remission of Gardner Diamond syndrome. Indian J Psychol Med. 2012;34(4):388–90.
7. Ratnoff OD. Psychogenic purpura (autoerythrocyte sensitization): an unsolved dilemma. Am J Med. 1989;87(3):16-21.
8. Campbell AN, Freedman MH, Mc Clure PD. Autoerythrocyte Sensitization. J Pediatr. 1983;103(1):157-60.
9. Barba A, Sapuppo A, Arosio C, Schiavon R. Gardner-Diamond Syndrome. Dermatologica. 1983;167(6):314-16.
10. Block ME, Sitenga JL, Lehrer M, Silberstein PT. Gardner-Diamond syndrome: a systematic review of treatment options for a rare psychodermatological disorder. Int J Dermatol. 2019;58(7):782-7.
11. Henneton P, Frank M, Litvinova E, Miranda S, Messas E, Darnige L. Syndrome de Gardner-Diamond: à propos d’un cas chez un homme jeune et revue de la littérature [Gardner-Diamond syndrome in a young man: A case report and literature review]. Rev Med Interne. 2017;38(9):623-7.
12. Sridharan M, Ali U, Hook CC, Nichols WL, Pruthi RK. The Mayo Clinic Experience With Psychogenic Purpura (Gardner-Diamond Syndrome). Am J Med Sci. 2019; 357(5):411-20.
13. Ivanov OL, Lvov AN, Michenko AV, Künzel J, Mayser P, Gieler U. Autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome): review of the literature. J Eur Acad Dermatol Venereol. 2009;23(5):499-504.
14. Uthman IW, Moukarbel GV, Salman SM, Salem ZM, Taher AT, Khalil IM. Autoerythrocyte sensitization (Gardner-Diamond) syndrome. Eur J Haematol. 2000;65(2):144-7.
15. Miranda JV, Vagner B. Gardner-Diamond’s syndrome: literature review. International J Collab Res Intern Med Public Health. 2012;4(4):268-75.
Download attachments: 10.4328:ACAM.20891
Hakan Kocoglu, Faruk Karandere, Emine Uzun, Dogancan Akyurek, Betul Erismis, Abdulbaki Kumbasar. A rare cause of severe ecchymosis: ‘Diamond-Gardner syndrome’. Ann Clin Anal Med 2022;13(Suppl 1): S49-52
Post-COVID-19 fibromyalgia syndrome: A report of two cases
Abdulsatar J. Mathkhor 1, Abdulnasser H. Abdullah 2, Amer S. Khudhairy 3
1 Department of Rheumatology, Basrah Teaching Hospital, 2 Department of Rheumatology, Alsader Teaching Hospital, 3 Department of Rheumatology, Alfayhaa Teaching Hospital, Basrah, Iraq
DOI: 10.4328/ACAM.20973 Received: 2021-11-25 Accepted: 2021-12-29 Published Online: 2022-01-05 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S53-55
Corresponding Author: Abdulsatar J. Mathkhor, Rheumatology unit in Basrah Teaching Hospital, Basrah, Iraq. E-mail: firstname.lastname@example.org Corresponding Author ORCID ID: https://orcid.org/0000-0002-3413-263X
COVID-19 is a viral infection caused by SARS-CoV-2 that primarily targets the respiratory system. COVID-19 may be followed in some patients by post-COVID-19 syndrome, fatigue, anxiety, and musculoskeletal pain. These symptoms may be associated with other symptoms, resulting in a constellation of symptoms consistent with fibromyalgia syndrome (FMS). Two patients were evaluated at the rheumatology outpatient clinic for diffuse persistent musculoskeletal pain after COVID-19 infection. Patients presented with generalized musculoskeletal pain, fatigue, anxiety, depression, headache, hand paresthesia, and non-restorative sleep. General examination and various laboratory investigations, including autoimmune profile and radiological investigation, were normal. After examining eighteen tender points, both patients fulfilled the 1990 ACR classification criteria for FMS. Post-COVID-19 FMS should be considered during the management of post-COVID-19 syndrome to alleviate pain and prevent worsening of symptoms during the COVID-19 pandemic.
Keywords: COVID-19, Fibromyalgia Syndrome, Fatigue
In December 2019, an outbreak of a novel coronavirus infection by SARS-COV-2 in China had become an international health emergency, causing coronavirus disease-19
(COVID-19) . The Coronaviridae family is a single-stranded RNA genome. Viral RNA released in host cell cytoplasm starts processes of translation, transcription, and replication, leading to downregulation of the Angiotensin-converting enzyme 2 (ACE2) receptors. As the immune system responds by expression of ACE2 of the host cell surface that binds to spike glycoprotein of the viral envelope, which in turn results in the release of angiotensin 2 and will stimulate type1a angiotensin 2 receptors in the lung, increasing pulmonary vascular permeability and lung damage . The diagnosis for Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection is largely based on Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) with a high rate of false-negative results and has been found largely inferior to that of a chest computed tomography. The most common manifestations associated with SARS-CoV-2 infection are fever, headache, chest pain, nausea, musculoskeletal pain, anxiety, fatigue, impaired visual acuity, depression, confusion, post-traumatic stress symptoms, and cognitive impairment . Since the recognition of SARS-CoV-2 infection in late 2019, there were clinical and laboratory emphasis on the respiratory manifestations. Post-covid syndrome is not merely one condition; it is defined by the National Institute for Health and Care Excellence (NICE) as “signs and symptoms that develop during or after COVID-19 infection and continue for more than 12 weeks that not explained by another diagnosis . Fatigue was one of the most common longer-term consequences of viral infection, Post-infectious fatigue and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) has also been observed after the onset of other epidemics like the Spanish Flu and the outbreak of the SARS-CoV virus, causing an epidemic of SARS in 2003, it is also observed in people recovering from H1N1 . Acute or chronic stress may trigger or aggravate the symptoms of Fibromyalgia Syndrome (FMS)  Fibromyalgia syndrome (FMS) is a chronic diffuse widespread pain condition associated with other symptoms, including morning stiffness, anxiety, fatigue, sleep disturbance, cognitive problems, and 18 tender points . It may result from or coexist with neuro-hormonal or immunologic disorders, genetic predisposition, infections, rheumatic diseases, physical trauma, or psychological illness .
The patient was a 43-years-old housewife who started to develop fever, generalized muscle and bone pain, dry cough, and severe shortness of breath. She was known to have controlled type 2 diabetes. Her investigations revealed: Hb 13.0 g/dl, WBC of 9.0×10³/mm³ with relative lymphopenia, platelets of 226×10³/mm³. The ESR was 58 mm/1st h, the CRP was positive (20.3 mg/L), D-dimer 360 ng/mL, ALT 16 U/l, AST 20 U/l, and HbA1c: 9.2%. PCRs for COVID-19, was positive. CT chest was normal. She was diagnosed with a case of COVID-19 infection and was given azithromycin 500 mg/day, aspirin at a low dose of 100 mg/d for 3 months, zinc, vitamin C, and vitamin D supplement. There was an improvement in her chest symptoms, normalized body temperature. However, the patient still complained of generalized muscle and bone pain, fatigue, and stiffness, especially in the early morning. Three months later, she developed progressive sleep disturbance, mood disturbance, anxiety with depressive symptoms. The patient was advised to take painkillers and to have a stress-free lifestyle, but with no improvement, investigations revealed Hb 13.7 g/dl, WBC 9.5×10³/mm³, platelets of 282×10³/mm³. CRP: 4.4 mg/L, serum ferritin: 80.1 ng/mL, D-dimer 250 ng/mL, ANA, RF and anti-CCP were negative. After a rheumatologic consultation, the diagnosis of FMS secondary to COVID 19 was considered with 15/18 tender points . Amitriptyline tablet 25 mg/day with vitamin D, vitamin C, and zinc supplement was started, and a month later, there was modest improvement in her wellbeing and mood status with12/18 tender points.
A 42-year-old worker presented with severe bone pain, myalgia, dyspnea, fever, and dry cough. He was a chronic heavy cigarette smoker 20 cigarettes/day and was apparently healthy and had no chronic diseases. His investigations revealed normocytic normochromic anemia, leukocytosis 12.3×10³/mm³, ESR 50, and CRP 12.8 mg/L. A chest x-ray revealed exaggerated bronchovascular markings. A chest CT showed pneumonic patches for which he received multiple antibiotics but with mild improvement. A nasopharyngeal swab was analyzed by RT-PCR and confirmed a SARS-CoV- 2 infection. His D-dimer was 320 ng/mL. He received azithromycin 500 mg/day orally for 5 d, hydroxychloroquine 400 mg/day, zinc, vitamin C and vitamin D supplements, mast cell stabilizer with moderate improvement. As the chest pain persisted, he quit smoking. Three months later, he developed sleep disturbance, severe generalized muscle and bone pains, morning stiffness, anxiety, and fatigue that lasted for further 3 months. The patient consulted a psychiatrist and was prescribed Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) for three weeks with mild improvement. After a rheumatological consultation, he was diagnosed with FMS according to the 1990 ACR criteria  with 17/18 tender points. Duloxetine 60 mg/day at night was added to his treatment. The patient was advised to lead a stress-free lifestyle, vitamin D, vitamin C, and zinc supplements were provided. At the follow-up examination three months later, the general condition of the patient improved. On examination, there were fewer tender points 11/18. The patient continued on the same medications with reassurance.
There are some different common underlying etiopathogenesis between COVID-19 and FMS. Researchers found that patients who contracted COVID-19 exhibited a ‘cytokine storm.’ Specifically, patients had increased levels of IL-2, IL-7, granulocyte-colony stimulating factor, interferon-γ inducible protein 10, monocyte chemoattractant protein 1, macrophage inflammatory protein-α, and tumor necrosis factor- α. Also researchers found associations between single nucleotide polymorphisms in cytokine genes and post-infection complications such as fatigue, pain, neurocognitive difficulties, and mood disturbances. Specifically, the associations were found with IL-6, TNF-α, IFN-γ, and IL-10. Furthermore, the researchers found that increased fatigue post-infection was associated with T allele of IFN-γ +874 T/A SNP . The cytokine storm experienced during the illness may persist and contributes to other complications such as prolonged fatigue. Cytokines that have been implicated in both post-infectious ME/CFS and COVID-19 such as IL-2, granulocyte-colony stimulating factor, and interferon-γ inducible protein 10 . From another perspective, inhibition of ACE 1 can enhance pain by blocking the degradation of substance P and bradykinin and enhancing kinin receptors signaling, resulting in fibromyalgia-like symptoms. Furthermore, the association of Angiotensin-Converting Enzyme 1 (ACE-1) gene polymorphism with FMS development has been addressed in the literature . The spike protein on the virus binds the ACE2 receptor, facilitating the entry into human cells and provoking antagonistic pathways of the renin-angiotensin system results in an imbalance of the ACE/ Angiotensin II and its receptor as well as the ACE2/ angiotensin /Mas receptor pathways. By inducing a decrease in membrane ACE2 receptors on host cells, an imbalance of ACE/ACE2 occurs that contributes to the pathogenesis of SARS-CoV-2 infection and triggers severe lung injury . In addition, the stress associated with the lock-down due to the COVID-19 pandemic leads to increased musculoskeletal pain, and numerous patients developed different FMS symptoms . Since hypertension is a frequent late effect of COVID-19 and is comorbidity affecting FMS patients, in such cases, hypertension treatment with ACE inhibitors should be avoided, and other classes of antihypertensive drugs should be preferable . Evidence suggests that these medications can upregulate the expression of angiotensin-converting enzyme 2 (ACE2), the cellular receptor for SARS-CoV-2. Thus, it is hypothesized that ACE2-increasing drugs could increase the risk of infection and prompt a more severe clinical course in hypertensive patients, which in turn may be related to post-COVID-19 sequelae like FMS .
FMS can be significant comorbidity in previous COVID infection. Post-COVID-19 FMS should be considered during the management of post-COVID-19 syndrome to alleviate pain and prevent worsening of symptoms during the COVID-19 pandemic.
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Conflict of interest
1. Mackenzie JS, Smith DW. COVID-19: a novel zoonotic disease caused by a coronavirus from China : what we know and what we don ’ t. Microbiol Aust. 2020; DOI: 10.1071/MA20013
2. Zou Z, Yan Y, Shu Y, Gao R, Sun Y, Li X, et al. Angiotensin-converting enzyme 2 protects from lethal avian influenza A H5N1 infections. Nat Commun. 2014;5:1–7.
3. COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188). London: National Institute for Health and Care Excellence; 2020. p.1–17.
4. Magnus P, Gunnes N, Tveito K, Bakken IJ, Ghaderi S, Stoltenberg C, et al. Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is associated with pandemic influenza infection, but not with an adjuvanted pandemic influenza vaccine. Vaccine. 2015;33(46):6173–7.
5. Tansey CM, Louie M, Loeb M, Gold WL, Muller MP, De Jager JA, et al. One-year outcomes and health care utilization in survivors of severe acute respiratory syndrome. Arch Intern Med. 2007;167(12):1312–20.
6. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The american college of rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33(2):160–72.
7. Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of fibromyalgia: The possible role of infection and vaccination. Autoimmun Rev. 2008;8(1):41–3.
8. Piraino B, Vollmer-Conna U, Lloyd AR. Genetic associations of fatigue and other symptom domains of the acute sickness response to infection. Brain Behav Immun. 2012;26(4):552–8.
Download attachments: DOI: 10.4328:ACAM.20973
Abdulsatar J. Mathkhor, Abdulnasser H. Abdullah, Amer S. Khudhairy. Post-COVID-19 fibromyalgia syndrome: A report of two cases. Ann Clin Anal Med 2022;13(Suppl 1): S53-55
A different and simple 3D planning process for stenting a ductus in a patient with truncus arteriosus
Akif Kavgacı 1, Semiha Tokgöz 1, Fatma İncedere 1, Osman Tunç 2, Serdar Kula 1
1 Department of Pediatric Cardiology, Faculty of Medicine, Gazi University, 2 Department of Medical Application Engineer, BTech Innovation, Ankara, Turkey
DOI: 10.4328/ACAM.21073 Received: 2022-01-22 Accepted: 2022-02-23 Published Online: 2022-02-24 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S56-58
Corresponding Author: Akif Kavgacı, Department of Pediatric Cardiology, Faculty of Medicine, Gazi University, 06560, Ankara, Turkey. E-mail: email@example.com P: +90 532 138 95 90 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7502-765X
Three-dimensional (3D) modeling is very useful and effective for surgical management, but it is also an expensive method. After 3D cardiac modeling was completed for our patient, a successful ductal stent intervention was performed. In this case report, a new 3D approach was used to improve the success of ductal stent intervention on a neonate with truncus arteriosus.
Our aim is to show that 3D modeling can aid in medical follow-up, angiographic, and/or surgical intervention decisions in congenital heart disease patients with difficult congenital heart disease.
Keywords: Truncus Arteriosus, 3D PDF, Ductal Stenting
Truncus arteriosus is a rare cardiac anomaly that constitutes 1-4% of all congenital heart diseases . It is characterized by a single arterial vessel originating from the ventricular region of the heart, sitting onto the ventricular septum and giving branches to the systemic pulmonary and coronary circulation . In the early period, surgical or transcatheter intervention saves lives and it is highly important to define the anatomy in the preoperative period.
CT angiography and 3D printing are two techniques that are commonly used to define cardiac anatomy. However, due to the high cost of 3D printing and the fact that CT images can only be viewed on radiology workstations or with special software, alternative methods have been developed. Based on our clinical experience, we believe that 3D PDFs can assist clinicians in providing affordable and effective solutions at this time. The stenting of a newborn with truncus arteriosus utilizing 3D PDF is the topic of this article.
Echocardiography of the infant indicated the diagnosis of truncus arteriosus, and prostaglandin treatment was initiated. At birth, his oxygen (O2) saturation in room air was 78%. The CT angiographic examination was performed on the first postnatal day. It was reported that the left pulmonary artery showed continuity with patent ductus arteriosus (PDA), whereas the right pulmonary artery was filled with collateral vascular structure diverting from the brachiocephalic trunk (Figure 1).
It was planned to apply a ductal stent to avoid the side effects of the prostaglandin infusion required to support the left lung and protect the patient from prostaglandin dependence. To show the anatomy more clearly and conduct a detailed assessment of the ductal stent plan before the procedure, the CT images were reformatted as a 3D PDF. Within the scope of this study, a 3D planning and modeling process was made using the Mimics Innovation Suite 22.0 (Ma¬terialize, Leuven, Belgium) software. The technique of this procedure was defined in our previous report . In this way, we were able to analyze cardiac images in detail and interactively, regardless of the CT platform. The blood vessels diverging from the truncal arch and reaching the lung were interactively analyzed in detail with their routes and lumen structures using the 3D PDF document that was prepared. On the 3D PDF document, the anatomy of the ductus arteriosus was clearly portrayed, and the size of the ductus arteriosus was measured at 3.38 mm (Figure 2 a,b). The information from the 3D PDF was crucial for the interventional process.
On the fifth day after birth, stent application was performed on the vertical ductus of the patient with an atypical localization and showed continuity with the left pulmonary artery. No complication was encountered during or after the procedure. After the procedure, due to the possible risk of thrombosis, prophylactic enoxaparin sodium and aspirin treatment was started. Echocardiography showed a well-positioned stent and patent flow through the stent. Prostaglandin treatment was ceased, and the oxygen saturation levels of the patient who did not receive prostaglandin during the monitoring period were 80-85%. Thrombosis was observed in the stent at the 36th hour of monitoring, and for this reason, tissue plasminogen activator (TPA) treatment was started. At the 6th hour of the TPA treatment, it was seen in the echocardiographic examination that the stent flow was laminar. The stent was thrombosed, and the blood flow inside the lumen was reduced according to an echocardiographic study performed 12 hours after the TPA treatment was completed. During the monitoring period, the patient’s O2 saturation levels remained between 60% and 70%. However, due to prolonged hypoxia and complications, the patient died on the 18th postnatal day.
Three-dimensional visualization has allowed a better understanding of the relationships among cardiac structures and opened new horizons in the treatment of patients with congenital heart diseases . The importance of 3D print materials is also getting higher day by day in determining the strategy before the procedure in cardiac surgery and interventional cardiology. Valverde et al. (2017) investigated the effects of 3D-printed models in 40 patients who were scheduled for complex congenital cardiac surgery and observed that these models created differences in the surgical method in 19 patients . 3D modeling was performed for a case with partial anomalous pulmonary venous return and sinus venosus type ASD before the intervention. 3D models demonstrated that placing the stent into the superior vena cava towards the right atrium would close the sinus venosus type defect. This way, by showing that it is possible to direct the pulmonary venous flow towards the left atrium, the procedure was implemented through the transcatheter route [4,6]. However, the costs of 3D modelling and printing processes are high. Therefore, as an alternative method that provides an opportunity for an examination as detailed as 3D-printed models, 3D PDF may provide great advantages before surgery and invasive interventional procedures .
The portable document format (PDF) is a de facto standard in the use of electronic documents today. A PDF file contains the data required for reconstructing 3D models without the need for an additional source. Additionally, 3D PDF has many advantages when compared to 3D CT images. Adobe Reader allows the user to accurately view 3D models and use options, such as zooming, scrolling, rotating or selecting relevant parts and exporting sections from the desired part. It works compatibly with all operating systems that are most prevalently used around the world (MS Windows, Mac OS, Linux) . Thus, any scenario can be tested on 3D PDF, and data exchange is possible between computers running different operating systems. Using 3D PDF does not require any additional specialized hardware or software. Also, in terms of data size, 3D PDF files require much less storage space than other 3D materials. Such factors provide all clinicians and medical students with the opportunity to easily benefit from 3D PDF. Due to these advantages, 3D PDF has been used at our clinic for a long time . To implement the stent successfully, it is important to define the ductal anatomy well before the procedure.
For imaging congenital cardiac abnormalities, CT angiography and 3D printing are commonly utilized procedures. Nevertheless, as the cost of 3D prints is high, and CT images can only be examined at radiology workstations or with specialized software, the need for using alternative methods has emerged. As in the case in our study, based on our clinical experience, it is thought that 3D PDF may help clinicians in the process of providing inexpensive and effective solutions.
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Animal and human rights statement
Conflict of interest
1. Hong SH, Kim YM, Lee C-K, Lee C-H, Kim SH, Lee SY. 3D MDCT angiography for the preoperative assessment of truncus arteriosus. Clin Imaging 2015;39(6):938-44.
2. Hallermann FJ, Kincaid OW, Tsakiris AG, Ritter DG, Titus JL. Persistent truncus arteriosus: A radiographic and angiocardiographic study. Am J Roentgenol Radium Ther Nucl Med. 1969;107(4):827-34.
3. Kula S, Tunç O, Kavgacı A, Incedere F. Demonstrating a rare anatomical variation of cardiovascular system by using a new technique. Anatolian Journal of Cardiology 2020;24(4):244.
4. Forte MNV, Hussain T, Roest A, Gomez G, Jongbloed M, Simpson J, et al. Living the heart in three dimensions: applications of 3D printing in CHD. Cardiol Young 2019;29(6):733-43.
5. Valverde I, Gomez-Ciriza G, Hussain T, Suarez-Mejias C, Velasco-Forte MN, Byrne N, et al. Three-dimensional printed models for surgical planning of complex congenital heart defects: an international multicentre study. Eur J Cardiothoracic Surg. 2017;52(6):1139-48.
6. Velasco Forte MN, Byrne N, Valverde I, Gomez Ciriza G, Hermuzi A, Prachasilchai P, et al. Interventional correction of sinus venosus atrial septal defect and partial anomalous pulmonary venous drainage: procedural planning using 3D printed models. JACC Cardiovasc Imaging. 2018;11(2 Part 1):275-8.
7. Mavar-Haramija M, Prats-Galino A, Méndez JAJ, Puigdelívoll-Sánchez A, De Notaris M. Interactive 3D-PDF presentations for the simulation and quantification of extended endoscopic endonasal surgical approaches. Journal of Medical Systems 2015;39(10):127.
8. Newe A. Towards an easier creation of three-dimensional data for embedding into scholarly 3D PDF (Portable Document Format) files. Peer J. 2015;3:e794.
Download attachments: 10.4328:ACAM.21073
Akif Kavgacı, Semiha Tokgöz, Fatma İncedere, Osman Tunç, Serdar Kula. A different and simple 3D planning process for stenting a ductus in a patient with truncus arteriosus. Ann Clin Anal Med 2022;13(Suppl 1): S56-58
Possible cause of low-inspired oxygen concentration during end-tidal controlled low- flow anesthesia technique with the aisys CS2 anesthesia machine: Case report
Department of Anesthesiology and Reanimation, Application and Research Center, Ankara City Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.21091 Received: 2022-01-30 Accepted: 2022-03-10 Published Online: 2022-03-13 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S59-62
Corresponding Author: Aysun Postaci, Department of Anesthesiology and Reanimation, Application and Research Center, Ankara City Hospital, 06610, Cankaya, Ankara, Turkey. E-mail: firstname.lastname@example.org P: +90 532 352 03 83 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4455-5342
It is reported that climate change, which is considered the biggest global health threat in the twenty-first century, can only be prevented by applying sustainability in healthcare. Sustainability in anesthesia can be achieved by anesthetists who control the flow of inhalation agents while meeting our daily needs, accept low-flow anesthesia (LFA) as the current anesthesia management method of our age and transfer their principles, knowledge and methods to practical applications in order to make the development sustainable. In this case report, we planned to present a brief case of temporary desaturation, which was immediately noticed during end-tidal controlled LFA applied with the GE Aisys CS2 anesthesia device and LFA, a component of sustainable anesthesia, in summary.
Keywords: General Anesthesia, Low Flow Anesthesia, End-Tidal Controlled Anesthesia
Due to environmental and economic concerns globally, the popularity of sustainability and, therefore, the concept of sustainable anesthesia is increasing. One of the most important components of sustainable anesthesia is Low Flow Anesthesia (LFA). With this anesthetic technique, the consumption of gas and inhalation agents is minimized, and a significant amount of cost and reduction in atmospheric pollution can be achieved. In addition to its many advantages, LFA also contributes to intraoperative protective lung mechanical ventilation techniques by improving the anesthetic gas climate and maintaining heat and humidity . Low-flow inhalation anesthesia can be administered with manual or end-tidal controlled methods. End-tidal controlled anesthesia devices automatically adjust the O2 flow and end-tidal concentrations of inhalation anesthetics set in the application of inhalation anesthesia by feedback and feeding. Less intervention is of clinical importance, similar to eliminating user distraction, record keeping, and patient safety . This case report aimed to present a possible problem during the end-tidal controlled LFA application in a training and research hospital providing residency training.
Radical abdominal hysterectomy was planned by the gynecology-oncology clinic for a 56-year-old patient weighing 86 kg due to endometrial carcinoma. During preoperative evaluation, the patient who had no concomitant disease other than the diagnosis of hypertension for four years was evaluated as ASA 2, and informed consent was obtained. The patient, taken to the operating table on the day of the operation, underwent standard anesthesia monitoring (ECG, non-invasive blood pressure, arterial pressure, pulse oximetry) , and 2 mg of midazolam iv was administered for premedication. In our institution, after reviewing the Low-Flow Anesthesia checklist (Figure 3), standard anesthesia induction (fentanyl 2 mcg/kg, lidocaine 1 mg/kg, propofol 2 -2.5 mg/kg, and rocuronium 0.6 mg/kg) was induced after three minutes of preoxygenation (Tidal volume method, 80% O2) was applied. After anesthesia induction, the patient was intubated with an endotracheal tube and connected to the GE Healthcare Aisys CS2 (F-890781) anesthesia device, and the lungs were mechanically ventilated (PCV mode) with TV 6-8 ml/kg and End-tidal CO2 30-35 mmHg. The lower and upper alarm limit values of the parameters monitored on the monitor were adjusted for the patient. Anesthesia was maintained for the first 5 minutes with a fresh gas flow of 4 L/min, 50 % O2 + 50 % air, and 2.5% sevoflurane. Remifentanil infusion was administered to provide intraoperative analgesia. After five minutes, the flow was reduced to 800 ml/min (50 % O2+ 50 % Air). In the following period, the anesthesia assistant informed the responsible specialist that the FiO2 decreased to 28% and gave an alarm. Meanwhile, SpO2 decreased from 98% to 94% (Figure 1, 2). The device was checked for possible causes, minute ventilation, expired tidal volume, airway peak pressures were reviewed, and no problem was detected in all these values. In the evaluation made by the specialist, it was noticed that the assistant adjusted the end-tidal O2 by 34% when the flow was reduced to 800 ml/min, thinking that end-tidal controlled ventilation was switched, and adjusted the O2 fresh gas flow to 34% in the fresh gas flow with manual control. After this situation, the fresh gas flow was increased to 4 L/min for a short time by remembering the long-time constant in low-flow anesthesia by the specialist physician. Then, the flow was reduced to 800 ml/min again, and the problem was resolved by switching to end-tidal controlled mode ( End-tidal O2 35%, End-tidal sevoflurane 1.7-2 %, MAC 0.8-0.9). During the anesthesia (4 hours), the alarm lower and upper limit values of the parameters set on the monitor were not reached again. After the first 3 hours of the operation, the gas flow was increased to 2 L/min for 30 minutes, and then reduced to 800 ml/min again and continued at 800 ml/min until the end of the surgery. In the last 15 minutes of the operation, remifentanil was stopped by intravenous administration of 10 mg of morphine sulfate and 1 g of paracetamol to provide acute postoperative analgesia. Fresh gas flow was continued at 4 L/min for the last 5 minutes before awakening, and the sevoflurane vaporizer was turned off, and the patient was extubated without any problems.
Sustainability is to meet our own needs without compromising the needs of future generations, and today, we see that more and more publications on sustainability in anesthesia take place in the literature. The General Medical Council of England stated that trained physicians should transfer the principles, knowledge, and methods of sustainable health care into their practical applications . Inhalation anesthetics are thrown into the atmosphere after use and remain in the atmosphere for years, contributing to climate change. Vollmer et al. reported measured atmospheric concentrations of inhalation anesthetics and showed that desflurane pollution gradually increased, sevoflurane remained static, and isoflurane decreased . Anesthesiologists are closely related to the use of resources, and due to the applied nature of the specialization, inhalation anesthetics have important contributions to the control of the fresh gas flow and thus to the environmental effects. In this context, it is reported that anesthetists should use LFA to contribute to environmental sustainability.
In our department, an education and research clinic, sustainability and LFA education is given theoretically and practically in the first years of residency training. LFA applications can be applied with all modern anesthesia devices that meet the American Society for Testing and Materials ASTM F1850–00-2005 and the European Standard EN 740 requirements .
Various smart visuals and alarm limits are available on different anesthesia machines to minimize human-induced errors in general anesthesia applications. As in our case, adjusting the upper and lower alarm limits for each patient undergoing general anesthesia in the initial period of anesthesia is important for the early detection of possible complications. It is mandatory to monitor the inspired O2 concentration, airway pressures and/or minute ventilation volume, and the concentration of inhalation agents in the circuit in this anesthesia technique . The oxygen concentration in fresh gas should be adjusted to at least 50% in low-flow anesthesia and 60% in minimal-flow anesthesia. In our case, all alarm lower limits (FiO2 30%, minute ventilation lower alarm limit 500-600 ml/minute below the existing minute ventilation value) were explicitly set for the patient during the initial period of anesthesia, and possible problems were investigated when FiO2 went below the set lower limit value. In addition to the many advantages of the Low Flow Anesthesia technique, one of the disadvantages claimed is the possibility of developing hypoxemia. In this technique, concentration changes in the fresh gas take a long time to cause the concentration change in the ventilation system (long time constant), which will create an extraordinary safety factor. However, today’s modern anesthesia machine and the anesthetist’s sufficient knowledge, and experience, in LFA reduce the probability of experiencing the alleged negativities.
Modern but expensive inhalational anesthetics such as desflurane and sevoflurane can be used safely and effectively in low-flow anesthesia techniques. Although Compound A, a degradation product formed by sevoflurane in LFA, is nephrotoxic in rats, its toxicity in humans has not been reported due to LFA use for a long time. Especially with the relatively new CO2 absorbents that do not contain KOH and, to a lesser extent, NaOH, Compound A is either not formed at all or to a lesser extent. Kobayashi et al. compared Draegersorb Free (NaOH < 2%) to Amsorb [Ca(OH)2] alone and found no difference in the amount of Compound A produced. Another study showed that Compound A levels in the circuit are reduced by using CO2 absorbents with reduced amounts of strong bases or eliminated by those without NaOH. Interestingly, they found that desiccation reduced Compound A produced when NaOH was present, increasing with Ca(OH)2 alone . In our clinic, the CO2 absorber KNGSORB (contains calcium hydroxide, sodium hydroxide, and ethyl violet) is used, and we do not have any concerns about Compound A formation since it does not contain KOH.
Checklists for routine situations in healthcare practice are organizational aids in complex tasks. It helps eliminate a decrease in performance and assists the individual user by providing standardized baseline information . Training in training and research hospitals is one of the core activities of these hospitals, and in this context, checklists also assist in residency training. We believe that the checklist created for LFA applications in our clinic contributes to the training in the initial period of residency training (Figure 3).
There are two low-flow anesthesia technique application methods: manual control and end-tidal control. Manually controlled low-flow anesthesia can be defined as a method in which oxygen and anesthetic gas titration are constantly controlled by the anesthetist, and manual adjustments are made to ensure adequate depth of anesthesia. In manually controlled low-flow anesthesia, many anesthetic gas dosage adjustments are required to ensure safe and appropriate anesthesia. End-tidal controlled low flow anesthesia is a method applied with advanced technological anesthetic devices, in which target fresh gas flow and the amount of end-tidal anesthetic gas are entered into the device, and the device automatically makes changes in the flows to achieve the target values. Less intervention of the anesthetist to the device may be clinically more important for patient safety and record keeping.
In our case, checklists must be created during anesthesia with the GE Aisys CS2 anesthesia machine. Again, we believe that the digital display adjustment buttons should be more prominent to avoid potential problems during the transition period from manual control technique to end-tidal control technique in this anesthesia device.
In conclusion, we think that sustainability in anesthesia and its component LFA technique, which is becoming more and more important for a sustainable environment, possible problems and checklists during the transition to manual and end-tidal controlled modes during anesthesia device training should be given from the early stages of assistantship.
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Conflict of interest
1. Upadya M, Saneesh PJ. Low-flow anaesthesia- underused mode towards “ sustainable anaesthesia”. Indian J Anaesth. 2018; 62(3):166-72.
2. Singaravelu S, Barclay P. Automated control of end-tidal inhalation anaesthetic concentration using the GE Aisys Carestation™. Br J Anaesth. 2013;110(4):561-6.
3. White M, Shelton L, Gelb AW, Lawson C, McGain F, Muret J, et al. Principles of environmentally-sustainable anaesthesia: a global consensus statement from the World Federation of Societies of Anaesthesiologists. Anaesthesia. 2022; 77(2):201–12.
4. Vollmer M, Rhee T, Rigby M, Hofsletter D, Hill M, Schoenenberger F. Modern inhalation anesthetics: potent greenhouse gases in the global atmosphere. Geophys Res Lett. 2015; 42: 1606–11.
5. Subrahmanyam M, Mohan S. Safety Features in Anaesthesia Machine. Indian J Anaesth. 2013;57(5):472-80.
6. Kobayashi S, Bito H, Morita K, Katoh T, Sato S. Amsorb Plus and Dragersorb Free, two new-generation carbon dioxide absorbents that produce a low compound A concentration while providing sufficient CO2 absorption capacity in simulated sevoflurane anesthesia. J Anesth. 2004;18(4): 277–81.
7. Vullia M, Tronet A, Fraumar F, Minville V, Fourcade O, Alacoque X, et-al. Training in intraoperative handover and display of a checklist improve communication during transfer of care. Eur J Anaesthesiol. 2017;34(7):471-6.
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Aysun Postaci. Possible cause of low-inspired oxygen concentration during end-tidal controlled low- flow anesthesia technique with the aisys CS2 anesthesia machine: Case report. Ann Clin Anal Med 2022;13(Suppl 1): S59-62
A new technique waiting to improve in the diagnosis of breast cancer: Contrast-enhanced mammography
Deniz Esin Tekcan Şanlı 1,2, Duzgun Yildirim 3
1 Department of Medical Imaging Techniques, Vocational School of Health Services, Istanbul Rumeli University, 2 Department of Radiology, Acibadem Kozyatagi Hospital, 3 Department of Medical Imaging Techniques, Vocational School of Health, Acibadem University, Istanbul, Turkey
DOI: 10.4328/ACAM.20720 Received: 2021-05-31 Accepted: 2021-08-19 Published Online: 2021-09-24 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S63-66
Corresponding Author: Deniz Esin Tekcan Şanlı, Department of Medical Imaging Techniques, Vocational School of Health Services, Istanbul Rumeli University, Istanbul, Turkey. E-mail: email@example.com P: +90 544 810 44 46 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6545-5757
The contrast-enhanced mammography technique, which was developed to reduce the false negativity and false positivity rates of full-field mammography, especially in dense breasts, and received FDA approval in 2011, has not been fully recognized even in the area of radiology. Based on this deficiency, this article aimed to give brief information about the advantages and disadvantages of contrast-enhanced mammography compared to digital mammography and breast magnetic resonance imaging, imaging technique, indications, and patient selection.
Keywords: Breast Cancer, Contrast-Enhanced Mammography, Dense Breast
The most common cancer in women is breast cancer. With screening mammograms since the 1960s, there have been a significant decrease in breast cancer-related mortality rates . With the widespread use of digital mammography in the 2000s, mammography has made great progress in diagnostic performance. It provides an opportunity for 2 or 3-dimensional tomosynthesis and computer-aided detection (CAD) scans . Now, it is possible to achieve higher predictive diagnostic results by making contrast-enhanced mammography (CESM) images, especially in dense breasts. In this context, contrast-enhanced mammography is an important radiological development that awaits widespread use.
Why Contrast-Enhanced Mammography?
Advantages compared to digital mammography
Patients with dense breast parenchyma, as Type C-D according to the American College of Radiology Breast Imaging Reporting and Data system (ACR-BIRADS), may be screened with contrast-enhanced mammography instead of classical mammography, since the sensitivity of conventional mammography decreases significantly. In such breasts, when mammography and ultrasonography are performing together, the diagnostic accuracy is 71%, while it can be reached 78-80% when performed with CESM . Studies show that the diagnostic accuracy of full-field digital mammography (FFDM) in breast cancer screening is 90% and ultrasonography is 92%, while the CESM sensitivity is close to 100% . In a study evaluating the advantages of CESM over FFDM, it has been shown that CESM increased sensitivity to 100% (+ 3%), specificity to 88% (+ 46%), positive predictive value (PPV) to 76% (+ 37%) and negative predictive value (NPV) to 100% (+ 3%) . In other words, CESM significantly reduces the false positivity rates of digital mammography; therefore, it reduces the rate of unnecessary follow-ups, examinations and procedures. If no pathological findings are detected in CESM, there is no need for additional examination for one year. This is especially important in reducing anxiety in patients with high risk or positive family history or in patients who will be followed up at short intervals upon suspicious findings. The most important advantage for radiologists; the learning curve is small compared to mammography, ultrasonography and magnetic resonance imaging (MRI). In other words, it is not a procedure that requires extensive experience as in mammography or MRI to evaluate .
Advantages compared to breast MRI
Neovascularization occurs with vascular endothelial growth factor (VEGF) released from rapidly growing tumoral lesions that usually go into partial necrosis secondary to malnutrition. Because of the high permeability of these vascular structures that develop rapidly and disorganized and are immature, the contrast material escapes to the tumor interstitium and enhances more than the ground breast tissue. This phenomenon is the basis for breast MRI and CESM .
Although magnetic resonance imaging is currently the gold standard in breast cancer diagnosis, lesion specificity is low, false positivity rates are high, the cost is very high, examination time is long, and it is not available in every center . MRI shows enhancement and increases unnecessary invasive procedures and biopsy rates with difficult procedures in lesions such as atypical ductal hyperplasia, benign fibrocystic disease, fibroadenoma, infection, papilloma, radial scar and complex sclerosing lesions . In addition, low grade-new-onset ductal carcinoma in situ (DCIS) or other malignant lesions may be negative for MRI since adequate enhancement is not observed. CESM provides anatomical and functional information in breast lesions with a lower cost and examination time, similar to MRI. The advantage of CESM is that it can detect suspicious findings such as microcalcification, distortion, and spiculation accompanying pathologies such as DCIS on low-energy images. Therefore, CESM is superior to MRI in detecting low-grade tumors and DCIS. Lesion specificity is also superior to MRI . In addition, dense ground parenchymal enhancement in dense and fibrocystic breasts significantly reduces MRI sensitivity. In cases with high-risk dense breast structure with dense breast parenchyma, MRI sensitivity decreases up to 77% . Therefore, CESM is superior to MRI to evaluate only tumor neovascularity by ruling out benign parenchymal enhancements, providing a non-complex, simpler and clearer image.
CESM is a growing technique for breast cancer detection and diagnosis, with the same levels of sensitivity and specificity as contrast-enhanced breast MRI. Because of its similar performance and ease of application, CESM is being adopted in multiple indications previously reserved for MRI, such as problem-solving, the extent of the disease in newly diagnosed patients, and evaluation of treatment response to neoadjuvant chemotherapy . In addition, the fact that the examination time is significantly shorter than MRI and eliminates false positivity rates of MRI is an important advantage in terms of practical use .
How is CESM performed?
Low osmolarity iodinated contrast agents similar to the contrast used for computed tomography (CT) are used to obtain contrast images. Contrast agent concentration should be 330-370 mg/ml. (e.g., Omnipaque, GE Healthcare). Contrast agents should be used at 1.5 mL/kg per kilo as in standard abdominal tomography scans. The injection rate of contrast material should be 2-3 mL/s. The breast is taken into compression approximately for 2 minutes after the injection, and dual-energy (low-energy (23–32 kVp) and high-energy (45–49 kVp)) images are taken in standard craniocaudal (CC) and mediolateral oblique (MLO) positions. Recombined images are created by subtracting low-energy images from high-energy images. That eliminates densities from the background breast tissue and highlights only areas of iodine uptake. It takes less than 6 seconds to acquire an image pair. Room time is slightly longer than standard mammography, nearly 10 minutes. Low and high energy beams are related to peak kilovoltage (kVp) and filtration. It is possible to say low-energy when the kVp value is 28-32; high-energy when the kVp value is 45-49 (Figure 1). Copper filters can be used to further harden the high-energy beam [12-14]. Recent estimates show that based on breast tissue thickness and density, the radiation dose delivered to the patient may be 81% higher for CESM than standard 2D digital mammography and 48% higher than 3D tomosynthesis with considering 2 separate radiation exposures per position for imaging .
FFDM sensitivity in ACR BIRADS Type C-D cases with dense breast structure does not exceed 30-60% [11-14]. It is the main indication to perform annual CESM instead of conventional digital mammography to screen patients with this dense breast parenchyma (Figure 2). Generally, all indications for breast MRI are also valid for CESM. It can be used to evaluate the distribution of a suspicious lesion detected in mammography, with its similar sensitivity to MRI. Again, it can be used instead of MRI in the local staging of the diagnosed cancer and in evaluating the other breast. It has been shown that CESM is as effective as MRI in evaluating the neoadjuvant treatment response. It can be used as an alternative to MRI, especially in cases where there is a contraindication for MRI such as pacemaker, claustrophobia, metallic foreign body.
Disadvantages of CESM
When CESM applies, even though the pulsed radiation exposure is shot twice (low-dose and high-dose) is considered the most important limitation of the examination, it is within safe limits. According to the American College of Radiology standards, the radiation dose to be exposed to a breast in a mammographic examination should not exceed 3 mGy. Despite twice exposures with CESM, high-quality images can generally be obtained with a dose of 1.7-2 mGy, under the limit of ACR. Therefore, the high radiation exposure dose can be ignored. However, using iodinated contrast material in such a screening examination is the most important disadvantage of the application. Adverse scenarios such as hypersensitivity reactions (<0.6% in last generation non-ionic iodinated contrast media and mild allergic reactions) and acute renal failure in patients with renal insufficiency (which can be minimized with abundant hydration) prevent the widespread use of the CESM. However, chest wall invasion and internal mammary lymph node involvement, which can mainly be detected by MRI and affect the stage in posterior-located tumors, cannot be clearly evaluated with CESM. That is one of the important weaknesses of the procedure. In these cases, it may be necessary to perform a complementary MRI after CESM [11-14].
Performing annual screening mammograms with CESM in high-risk patients will provide an advantage in terms of diagnosis. In patients with a lifetime risk of breast cancer is 20%, in BRCA or other hereditary germline mutation carriers, patients with a history of radiation to the chest wall, patients diagnosed with LCIS in any breast, patients with a family history of breast cancer under the age of 40, in cases with breast cancer in their first and second-degree relatives, CESM can be used instead of FFDM for screening purposes .
CESM is a reliable and practical imaging method that increases diagnostic sensitivity and specificity of mammography, reduces unnecessary interventional procedures and recall rates in the diagnosis of breast cancer, especially in high-risk patients with dense breast structure. Although the use of CESM in the world is low for now, it is an important radiological development that may increase rapidly when many potential indications and advantages for clinical use are considered.
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Conflict of interest
1. Loberg M, Lousdal ML, Bretthauer M, Kalager M. Benefits and harms of mammography screening. Breast Cancer Res 2015;17:63
2. Patel BK, Lobbes MBI, Lewin J. Contrast Enhanced Spectral Mammography: A Review. Semin Ultrasound CT MR. 2018;39:70-79
3. Dromain C, Thibault F, Diekmann F, Fallenberg EM, Jong RA, Koomen M, et al. Dual-energy contrastenhanced digital mammography: Initial clinical results of a multireader, multicase study. Breast Cancer Res 2012;14:R94
4. Luczynska E, Heinze S, Adamczyk A, Rys J, Mitus JW, Hendrick E. Comparison of the mammography, contrast-enhanced spectral mammography and ultrasonography in a group of 116 patients. Anticancer Res 2016;36:4359-4366
5. Lobbes MB, Lalji U, Houwers J, Nijssen EC, Nelemans PJ, van Roozendaal L, et al. Contrast-enhanced spectral mammography in patients referred from the breast cancer screening programme. Eur Radiol 2014;24:1668-1676
6. Lalji UC, Houben IP, Prevos R, Gommers S, van Goethem M, Vanwetswinkel S, et al. Contrast-enhanced spectral mammography in recalls from the Dutch breast cancer screening program: Validation of results in a large multireader, multicase study. Eur Radiol 2016;26:4371-4379
7. Kerbel RS. Tumor angiogenesis: Past, present and the near future. Carcinogenesis 2000;21:505-515
8. Li L, Roth R, Germaine P, Ren S, Lee M, Hunter K, et al. Contrast-enhanced spectral mammography (CESM) versus breast magnetic resonance imaging (MRI): A retrospective comparison in 66 breast lesions. Diagn Interv Imaging 2017;98:113-123
9. Perry H, Phillips J, Dialani V, Slanetz PJ, Fein-Zachary VJ, Karimova EJ, et al. Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting. AJR Am J Roentgenol. 2019;212:222-231
10. Jochelson MS, Dershaw DD, Sung JS, Heerdt AS, Thornton C, Moskowitz CS, et al. Bilateral contrast-enhanced dual-energy digital mammography: feasibility and comparison with conventional digital mammography and MR imaging in women with known breast carcinoma. Radiology 2013;266:743-751.
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12. Bhimani C, Matta D, Roth RG, Liao L, Tinney E, Brill K, Germaine P. Contrast-enhanced Spectral Mammography: Technique, Indications, and Clinical Applications. Acad Radiol 2017;24:84-88
13. Zanardo M, Cozzi A, Trimboli RM, Labaj O, Monti CB, Schiaffino S, et al. Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review. Insights Imaging. 2019;10:76.
14. Perry H, Phillips J, Dialani V, Slanetz PJ, Fein-Zachary VJ, Karimova EJ, Mehta TS. Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting. AJR Am J Roentgenol. 2019;212:222-231.
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Deniz Esin Tekcan Şanlı, Duzgun Yildirim. A new technique waiting to improve in the diagnosis of breast cancer: Contrast-enhanced mammography. Ann Clin Anal Med 2022;13(Suppl 1): S63-66
Different feeding methods for cleft lip and palate-a systematic review
Siraj DAA Khan 1, Ali Hussain Bin Mohammed Almansour 2, Abdullah Mehdi R. Al-Monajam 2, Rayed Saeed Ali Al Mahri 2, Meshari Salem Mahdi Al Mahri 2
1 Department of Pediatric Dentistry, 2 General Dental Practitioner, Faculty of Dentistry, Najran University, Najran, KSA
DOI: 10.4328/ACAM.20904 Received: 2021-10-12 Accepted: 2021-11-04 Published Online: 2021-11-10 Printed: 2022-03-15 Ann Clin Anal Med 2022;13(Suppl 1): S67-70
Corresponding Author: Siraj DAA Khan, Faculty of Dentistry, Najran University, KSA. E-mail: firstname.lastname@example.org P: +96 617 542 79 60 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7015-2232
Aim: Children born with cleft lip or palate usually face many difficulties in feeding. Therefore, proper feeding methods are necessary for those children. The aim of this review is to compare different feeding methods for CLP (cleft lip and palate) as well as evaluate the best method for them.
Material and Method: This study covered the articles between 2000 and 2020. Related articles were selected and discussed for further extraction of data.
Results: Use of syringe, paladai bottle and bottle which is squeezable was considered best before the surgery. While the suction method was considered the best after the surgery.
Discussion: The suction method could be appropriate for CLP children, but the result showed that alternative methods were considered well.
Keywords: Syringe Paladai, Bottle, Cleft Lip, Cleft Palate
Cleft lip and palate (CLP) are inherited deformities, which can affect lip, palate, or both  causing errors in facial fusion development in embryo  due to modifications in the normal development of primary as well as the secondary palate . These children experienced many difficulties including deficiency of nutrition, front teeth deformities, otitis media and change or delay in the development of speech. It is a very challenging process to feed the CLP children and in nursing, the most important task is to educate parents about successful feeding . Type and severity of cleft are the bases for feeding complexity in CLP infants. At the start, gain in weight can be a problem for nutritional deficiency and based on gender, they can have different problems [5,6] When these children face such problems, they cannot develop normally and failed to adopt the social behavior, so they became incapable of accepting different social behaviors. In children, the nutritional problem is a general behavioral problem (Ashby JM: Feeding therapy and techniques for children with cleft lip/palate. C 2011. Available at: http://opensiuc.lib.siu.edu/cgi/viewcontent), which is observed in 25–50% of healthy infants.
Feeding difficulty is the most frequently reported problem concerned with CLP. These include the absence of effective sucking because of the failure of proper negative pressure, chocking and milk vomiting via nasal cavity due to defects in the palate and facial structure resulting in less intake of food . Children with CP (Cleft palate) faced more difficulties in feeding . As a consequence, these children have the poor status of nutrition compared to others and gain weight improperly [7,9]. Furthermore, these complications have negative impacts on children’s development and growth . Various methods are present to solve these problems in oral clef infants. Supplementary feeding along with breastfeeding is advised for infants to overcome their nutritional value . Surgery is required for many reasons, including feeding.
The major distress for parents is feeding, as their children were diagnosed with a cleft lip/palate . At the start, monitoring infant nutrition and weight is the main priority . Surgery is considered the early treatment for patients with CLP. For lip palate, surgery is advised by three months, and for palate cleft 9 or 12 months are recommended, as the chronology of the method needs some changes, which depend on the center . It is also important for the children to have proper nutrition so they can bear the different factors of surgery such as stable weight gain without changing health and the ability to receive anesthesia safely . It is predicted that after surgery, children will face fewer feeding problems because many oral structures will be repaired. After surgery (palatoplasty), suction is recommended instead of BF/bottle for 6 weeks. Several centers followed protocols in which nipples and bottles were forbidden for 30 days . Generally used techniques to aid in oral feeding for CP and CL infants include oral facilitation, positioning, pacing and assisted fluid delivery and variations in the fluid viscosity.
Based on the available literature, the aim of this systematic review is to compare different feeding methods for children with cleft lip and palate and to evaluate the best feeding method for children before and after surgery.
Material and Methods
The search of the literature was carried out from 2000 to 2020. The search was executed in the PubMed/ Science Direct and Google Scholar databases because they contained most of the publications in this field. The search was conducted using the following Mesh terms: ‘‘Cleft palate; cleft lip; lip and palate cleft; feeding methods for cleft; feeding methods for lip and palate cleft’’.
Papers, which compared different methods of feeding recommended for cleft children with the level of evidence 1b to 4 as proposed by the American Speech-Language-Hearing Association (ASHA) were included in this review. Those studies that described syndromes linked with CLP were excluded. For further integration, a manual search was conducted in chosen papers.
The authors reviewed the articles to assess whether they meet the criteria or not. Then they read the full articles for extraction of data. The chosen data were then discussed by the authors.
Initially, related articles were searched. Various articles were excluded on the basis of abstract and title because they were not comparing the different feeding methods of CLP children. After discussion by the authors, 9 studies were selected for this systematic review. These studies discussed the different conditions of feeding and linked methods. The characteristics of different feeding methods included were: methods which required BF and suction, do not require suction cup, feeding route alteration i.e., nasogastric tube, paladai, syringe and spoon and the attributes/parameters that were assessed in these studies were: performance of feeding, complication and time of feeding, growth and nutritional gain, volume and acceptance of ingested food, fistula presence and related complications, pain, analgesia, duration of stay in hospital and costs. Although breastfeeding is encouraged for CLP children, most of them did not perform well with bottle feeding and BF before surgery.
It has been reported that using a syringe for feeding is easy, practical, spent less time, less vomit and cause significant gain in weight . Ravi et al. used a less known, alternative technique method, in which effects of different feeding methods i.e., with bottle, spoon and paladai on the pattern of weight gain were compared. Children fed with paladai showed greater improvements . Though paladai use is not common, those studies are important which evaluate less common methods because these techniques ease the intake of food and energy-efficient for CLP children  Similarly, a study compared the spoon vs. bottle and spoon and exhibited very similar results. The group which use spoon and bottle showed better result and group that use spoon faced discomfort . When syringe/spoon was compared with bottle/BF, although they represented similar results but parents showed more satisfaction with bottle/ BF . The methods that did not use suction caused irritation which lead to tearful and restless. Suction is very important  and create bonding between child and mother and also develop oral motor skills . A study said that those children fed via the nasogastric tube were more stable and they discharged from the hospital earlier. Parents were more satisfied while the other group which fed by using bottle showed rejection in feeding and prolonged and frequent feeding  After surgery, the tube can damage the repair and may cause pain . A study reported that the use of a spoon presented best as it showed less escape and more acceptance of food . Another benefit with spoon feeding is that it provides high contraction of the muscle and oral stimulation as compared to use of cup .
After surgery, the appropriate method of feeding for the children who have cleft lip/palate is suction. However, in some cases the alternative techniques e.g., syringe, bottle and paladai may be performed well. However, more studies are required for feeding methods before surgery.
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Conflict of interest
1. Jesus MSV, Kings C. Perceptive study of oral and nasal vowels in individuals with cleft palate. J Bras Phonoaudiol. 2002;3(11):121-6.
2. Cardim VL. Craniofacial growth. In: Altmann E, editor. Labiopalatine fissues. Barueri: Pro-Fono; 2005. p.31-8
3. Marques RMF, Lopes LD, Khoury RBF. Embryology. In: Altmann E, editor. Cleft lip and palate. Barueri: Pro-Fono; 2005. p. 3-23.
4. Scott RS, Terri K. Nutrition in children. In: Scott RS, Terri K. New York: Lippincott Williams and Wilkins; 2009. p. 807.
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Siraj DAA Khan, Ali Hussain Bin Mohammed Almansour, Abdullah Mehdi R. Al-Monajam, Rayed Saeed Ali Al Mahri, Meshari Salem Mahdi Al Mahri. Different feeding methods for cleft lip and palate-a systematic review. Ann Clin Anal Med 2022;13(Suppl 1): S67-70