Supplement 2 2024
Determining the effect of diet quality on nutritional status and type 2 diabetes risk in adult females
Ecem Özge Uray 1, Nazlı Batar 2, Tuğba Tuna 2
1 Department of Nutrition and Dietetics, Özel Maltepe Ersoy Hospital, İstanbul, 2 Department of Nutrition and Dietetics, Faculty of Health Sciences, Mudanya University, Bursa, Turkey
DOI: 10.4328/ACAM.22409 Received: 2024-09-16 Accepted: 2024-10-16 Published Online: 2024-10-18 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S62-66
Corresponding Author: Tuğba Tuna, Department of Nutrition and Dietetics, Faculty of Health Sciences, Mudanya University, Bursa, Turkey. E-mail: tugba.tuna@mudanya.edu.tr P: +90 539 916 71 53 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6034-7768
Other Authors ORCID ID: Ecem Özge Uray, https://orcid.org/0000-0001-9076-591X . Nazlı Batar, https://orcid.org/0000-0001-9527-5709
This study was approved by the Ethics Committee of Okan University (Date: 2021-12-29, No: 147/17)
Aim: This study aimed to determine the effect of diet quality on nutritional status and type 2 diabetes risk in adult females.
Material and Method: This study was conducted between January and March 2022 with the participation of 120 adult females who applied to Özel Maltepe Ersoy Hospital, Nutrition, and Diet Polyclinic for body weight control. The researchers recorded participant information form, IPAQ-SF, 24-hour retrospective food consumption record form, and FINDRISK data through face-to-face interviews. NAR and MAR scores were used to determine the diet quality of individuals.
Results: It was determined that as body weight, BMI, waist circumference, waist-height ratio, neck circumference, body fat percentage, and fat mass values increased, the diabetes risk scores of individuals increased (p<0.05). It was determined that decreasing lean body mass and percentage increased the risk of diabetes (p<0.05). Biochemical parameters FBG, Insulin, HOMA-IR, TC, LDL-C, and TG values were found to be higher in individuals with high and very high diabetes risk compared to other individuals (p<0.05). It was determined that the risk of diabetes decreased as the physical activity levels of individuals increased (p<0.05). Diabetes risk score, and it was determined that there was no correlation between the biochemical parameters (p>0.05).
Discussion: It has been determined that individuals’ anthropometric values, body composition, and physical activity level are important factors in the risk of diabetes. Appropriate health policies should be developed considering this situation.
Keywords: Nutritional Status, Type 2 DM, Diet Quality
Introduction
The prevalence study conducted regularly by the Turkish Diabetes Epidemiology Study Group (TURDEP II) in our country determined that diabetes mellitus (DM) is 14.6% prevalent in adults and elderly individuals [1]. In a report published in 2000, the World Health Organization (WHO) estimated that the number of individuals with DM would increase by approximately 3.5 million by 2030; however, this number was reached in 2014 [available at:https://www.who.int/publications/i/item/definition-and-diagnosis-of-diabetes-mellitus-and-intermediate-hyperglycaemia]. The low level of physical activity in society and the adoption of a low-quality diet are the reasons for the increase in the incidence of DM. In type 2 DM, a quality diet treatment should be applied to ensure blood glucose regulation. Therefore, healthy and quality nutrition forms the basis of therapy for type 2 DM [2].
Consuming foods with high energy content and low nutritional value, as well as fast food and high-energy drinks, increases the risk of obesity. A diet rich in dietary fiber and a low glycemic index reduces the risk of obesity [3]. In the study by Saraf-Bank et al., high diet quality positively affected some biochemical parameters [4]. It was determined that BMI, waist circumference, and body fat mass increases were associated with low diet quality [5].
This study aimed to determine the effect of diet quality on nutritional status and Type 2 DM risk in adult females.
Material and Methods
The study universe consisted of 170 females who applied to Okan Hospital Nutrition and Diet Polyclinic between January and March 2021. The sample size was calculated at a 95% confidence level using the Raosoft Sample Size Calculator program based on the universe number, and the minimum number of people to be included in the study was determined as 119 people. This cross-sectional study was conducted on 120 adult females who applied to Özel Maltepe Ersoy Hospital Nutrition and Diet Polyclinic for body weight control between January and March 2022. The inclusion criteria for the study were determined as follows: the participants were female, between the ages of 19 and 65, were not pregnant or lactating, did not have any problems speaking and understanding Turkish, and participated in the study voluntarily. Participant information form prepared by the researchers by compiling the literature, International Physical Activity Questionnaire-Short Form (IPAQ-SF), “three-day 24-hour retrospective food consumption record form used in calculating diet quality” and Finnish Diabetes Risk Score (FINDRISC) were applied to individuals who met the participation conditions by face-to-face interview. Regularly calibrated Inbody 270®, a Bioelectrical Impedance Analysis (BIA) device, was used to measure body weight and composition. When individuals apply to the hospital, the biochemical parameters that are routinely measured are Fasting Blood Glucose (FBG) mg/dL, Fasting Insulin mg/dL, Homeostatic Model Assessment Insulin Resistance (HOMA-IR), Total Cholesterol (TC) mg/dL, Low-Density Lipoprotein-Cholesterol (LDL-C) mg/dL, High-Density Lipoprotein-Cholesterol (HDL-C) mg/dL, Triglyceride (TG) mg/dL and Thyroid Stimulating Hormone (TSH) mU/mL and were recorded in the participant information form. After applying to the clinic, the individuals participating in the study were questioned about their food consumption for three consecutive days, one on the weekend and two on the weekdays. Food consumption was recorded in the BEBİS 7.2 program, and the energy and macronutrient elements consumed by the individuals were calculated. Nutrient Adequacy Ratio (NAR) and Mean Adequacy Ratio (MAR) are based on comparing the nutrient intakes of individuals with reference values. Individuals who volunteered to participate in the research were asked to read and sign the Voluntary Consent Form.
Statistical Analysis
The responses to the questionnaire and scale questions directed to the individuals for the research were recorded in the SPSS Statistics 22 program for analysis. “Student’s t-test” was used for the difference between two independent groups, ‘Mann Whitney U test’ was used for the comparison of two parameters that do not conform to normal distribution, ‘Anova test’ was used for the comparison of at least three groups of numerical variables that show normal distribution, and ‘Kruskal Wallis test’ was used for the comparison of at least three groups that do not show normal distribution. The relationship between two independent categorical variables was tested by chi-square analysis. The relationship between two numerical parameters was analyzed using a bivariate correlation test. The statistical significance level in the tests was evaluated as p<0.05.
Ethical Approval
This study was approved by the Ethics Committee of the Okan University Science, Social, and Non-Interventional Health Sciences Research Ethics Committee (Date: 2021-12-29, No: 147/17).
Results
This study was conducted with 120 adult females with a mean age of 38.7±13.56 years. The average body weight of the individuals was 79.3±15.16 kg, and the average BMI was 30.4±6.09 kg/m2. The proportion of individuals with an average waist circumference value was determined as 13.3%; the proportion of individuals in the risk and high-risk groups was determined as 23.4% and 63.3%, respectively. The average FBG value was 99.9±14.96 mg/dL, and the TC value was 204.7±45.24 mg/dL. The proportion of individuals not doing physical activity was 93.3%, and the proportion of individuals doing insufficient physical activity was 6.7%. The average Metabolic Equivalent Task (MET) value of the individuals was calculated as 171.0±241.64 min/week. Body weight, BMI, Waist circumference, body fat percentage, and body fat mass averages were higher in individuals who did not do physical activity than in individuals who did insufficient physical activity; however, no statistical significance was found (p>0.05). Lean body percentage value was calculated as 58.4±7.11% in individuals who did not do physical activity and 66.89±10.83% in individuals who did insufficient physical activity. Statistical significance was found between these two means (p<0.05).
Table 1 evaluates individuals’ diet quality scores and diabetes risk scores according to the classification of anthropometric measures. The rate of individuals with high diet quality was 91.7%, while the rate of individuals with inadequate diet quality was 1.6%. The total diet quality score was defined as 114.0±27.81 points. Diet scores of individuals with normal body weight (104.3±17.57) were found to be significantly lower than the diet scores of obese individuals (121.4±33.82) (p<0.05). The diet quality scores of individuals with waist circumference and waist-height ratio in the normal range were significantly lower than those in the other group (p<0.05). No significant difference was found between biochemical parameters and diet quality classification (p>0.05). The mean diabetes risk score of individuals with normal body weight (6.9±5.22) was found to be significantly higher than the scores of overweight (12.5±4.53) and obese (20.3±3.47) individuals (p<0.05). The diabetes risk score of individuals with waist circumference, waist-height ratio, and neck circumference in the normal range was lower than that of individuals in the risk group (p<0.05). Lean body mass and lean body percentage values were found to be significantly higher in individuals with low and mild diabetes risk than in individuals with high and very high diabetes risk (p<0.05).
The average biochemical parameters of individuals according to diabetes risk classification are given in Table 2. According to this table, FBS, insulin, HOMA-IR, TC, LDL-C, and triglyceride values were higher in individuals with high and very high diabetes risk than in others (p<0.05). In the current study, the diet quality score did not differ according to diabetes risk classification (p>0.05). When the anthropometric measurements of individuals were evaluated according to their diabetes risk classification, it was determined that 51.5% of individuals with a high risk of diabetes and 94.1% of individuals with a very high risk of diabetes were obese (p<0.05). There was no individual with a high-risk waist circumference among individuals with low diabetes risk. It was determined that all individuals with very high diabetes risk had a high-risk waist circumference (p<0.05). A significant relationship was found between waist-height ratio and neck circumference classification and diabetes risk classification (p<0.05).
It was found that as the IPAQ-SF score, lean body mass, and percentage of individuals increased, FINDRISK scores decreased (p<0.05). It was found that as body weight, BMI, waist circumference, waist-height ratio, neck circumference, body fat percentage, and fat mass values increased, diabetes risk scores of individuals increased (p<0.05). It was found that there was no correlation between diabetes risk score and biochemical parameters (p>0.05) (Table 3).
Discussion
This study was planned to determine the effect of diet quality on nutritional status and Type 2 DM risk in adult females. Today, due to changing diets and low physical activity levels, there are disruptions in the balance of energy intake, which paves the way for obesity. Obesity brings with it many complications. One of these complications is Type 2 DM. In the treatment of this disease, it is essential to have a quality diet treatment to control blood glucose levels [2]. Diet quality is seen to have a very influential role in preventing and treating DM [6].
The average BMI of the individuals in the study was determined as 30.4±6.09 kg/m2. It was determined that 37.5% of the individuals were overweight, and 44.2% were obese. In a survey conducted in Cyprus to determine nutritional status, women’s average BMI was 24.9±5.4 kg/m2. The average waist circumference was found to be 83.4±16.6 cm [7], while in a study conducted in Istanbul, the prevalence of obesity in individuals was determined to be 6.7% [8]. This rate is considered high since our study was conducted by individuals who applied for body weight control.
It was determined that none of the individuals participating in the study did sufficient physical activity. The rate of individuals who did not do physical activity was 93.3%, and the rate of individuals who did insufficient physical activity was 6.7% in the study conducted by Aslan et al. [9], it was concluded that the rate of females who did physical activity was 7.8%. In a study of professionals working at a desk, the proportion of individuals doing sufficient activity was only 11.0% [10]. The employment status of the individuals was not questioned in this study, but it was determined that 82.5% had a high school education or higher. Considering that the individuals worked desk jobs, this situation can be associated with the high rate of individuals who did not engage in physical activity.
Diet quality is a concept related to the nutritional habits of individuals [11]. Studies have stated that a quality diet plan reduces the risk of developing chronic diseases and contributes to the quality of life of individuals [12, 13]. In our research, the rate of individuals with high diet quality was determined as 91.7%, the rate of those who need to be improved as 6.7%, and the rate of those who are inadequate as 1.6%. In the study of Yosaee [14], the rate of individuals with high, moderate, and low diet quality was determined as 0.7%, 55.9%, and 43.4%, respectively. In this study, the diet scores of individuals with average body weight were significantly lower than those of obese individuals (p<0.05). When the literature is examined, the number of studies indicating that diet quality and BMI have an inverse relationship is relatively high [4, 14]. Studies suggest that the relationship between diet quality and body composition is unclear and that the relationship between diet quality and BMI is insignificant for females. This is because females may have healthier eating habits even with a high BMI [15, 16]. The fact that our study yielded results that were opposite to those of the literature can be explained by the fact that the NAR and MAR score scales we used were unsuitable for our sample and that these scores are used to measure nutritional deficiencies, especially in developed countries. It is thought that the NAR and MAR scores yielded results opposite to those of the literature in a sample with a high obesity rate because values such as total energy intake, sodium, and cholesterol were not evaluated by [17].
In the study, the proportion of individuals with low, mild, moderate, high, and very high diabetes risk scores was determined as 11.7%, 20.0%, 12.5%, 27.5%, and 28.3%, respectively. In a study in which diabetes risk was measured using the FINDRISK scale, the proportion of individuals with low, mild, moderate, high, and very high diabetes risk scores was determined as 11.1%, 39.1%, 22.9%, 23.8%, and 3.2%, respectively [18]. In another study conducted in Italy for a similar purpose, the proportion of individuals with very high diabetes risk was 4.9% [19]. A cross-sectional study in our country stated that 15.1% of individuals were in the high and very high-risk groups [20]. The high proportion of individuals with high and very high diabetes risk in this study can be associated with the high rate of individuals being overweight and obese.
In the study, the diabetes risk score average of individuals with normal body weight was found to be significantly lower than the score of overweight and obese individuals. The diabetes risk score of individuals with waist circumference, waist-height ratio, and neck circumference within the normal range was lower than that of individuals in the risk group. In addition, body weight, BMI, waist circumference, waist-height ratio, body fat percentage, and body fat mass average were found to be significantly higher in individuals with very high diabetes risk compared to other individuals. Lean body mass and lean body percentage values were found to be significantly higher in individuals with low diabetes risk and lightweight compared to individuals with high and very high diabetes risk. Studies have reported that the risk of DM increases as BMI and waist circumference increase [21, 22]. A cohort study determined that losing body weight reduced the risk of Type 2 DM [23]. A high BMI value causes an increase in free fatty acids in the body. This leads to increased blood glucose levels and decreased insulin secretion, which leads to adverse effects [24].
Limitations of the Study
Our study was conducted between January and March 2022, and only with individuals who applied to Özel Maltepe Ersoy Hospital Nutrition and Diet Clinic for body weight control, and the community who did not apply to the health institution was not screened. In addition, surveys such as 3-day food consumption records and questionnaires are based on the statements of individuals. Despite this, the survey forms obtained with the statements of individuals in our study were meticulously checked, and the accuracy of the forms was confirmed by the individuals who participated in the research and were added to the survey.
Conclusion
In conclusion, as the BMI values of individuals in the current study increase, the risk of diabetes also increases. The diabetes risk of individuals with waist circumference, waist-height ratio, and neck circumference in the normal range was lower than the score of individuals in the risk group. FBS, insulin, HOMA-IR, TC, LDL-C, and triglyceride values were found to be higher in individuals with high and very high diabetes risk compared to others. There were no obese individuals among individuals with low diabetes risk. There were no individuals with normal BMI among individuals with very high diabetes risk. It was determined that the diabetes risk of individuals decreased as their physical activity levels increased. As body weight, BMI, waist circumference, waist-height ratio, neck circumference, body fat percentage, and fat mass values increased, the diabetes risk scores of individuals increased. It was determined that the decrease in lean body mass and percentage also increased the risk of diabetes. As a result of our study, it was determined that anthropometric values, body composition, and physical activity level were quite influential in reducing the risk of diabetes.
For this reason, society should be screened with health policies developed before people can apply to a health institution. Dietitians should also educate people about nutrition, especially in schools. The diet quality scale we used in our study did not provide results that align with the literature; however, this study should be conducted on a larger sample using another diet quality scale instead.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and Human Rights Statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Download attachments: 10.4328.ACAM.22409.pdf
Ecem Özge Uray, Nazlı Batar, Tuğba Tuna. Determining the effect of diet quality on nutritional status and type 2 diabetes risk in adult females. Ann Clin Anal Med 2024;15(Suppl 2):S62-66
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Cerebral palsy patient who developed mortal complications following hip surgery: A case report
İdris Çoban 1, Mehmet Fethi Ceylan 2
1 Department of Orthopaedics and Traumatology, Faculty of Medicine, İnönü University, Malatya, 2 Department of Orthopaedics and Traumatology, Faculty of Medicine, Ömer Halisdemir University, Niğde, Turkey
DOI: 10.4328/ACAM.22027 Received: 2023-10-27 Accepted: 2024-07-29 Published Online: 2024-08-08 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S67-69
Corresponding Author: İdris Çoban, Department of Orthopaedics and Traumatology, Faculty of Medicine, İnönü University, Malatya, Turkey. E-mail: idriscoban21@hotmail.com P: +90 422 341 06 60 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8861-2922
Other Authors ORCID ID: Mehmet Fethi Ceylan, https://orcid.org/0000-0003-1466-0790
Patients with cerebral palsy (CP) may develop complications such as infection or repeat dislocation following orthopedic surgery and rarely, mortal complications. A 7-year-old male CP patient underwent an iliac and femoral osteotomy due to a hip dislocation. Following the operation, the patient was discharged with a stable condition, but was admitted to the intensive care unit 3 days later after his clinical condition deteriorated. Detailed examination showed that the patient was experiencing hypovolemic shock due to gastrointestinal bleeding and died on the 3rd day of follow-up in the intensive care unit despite all revival efforts. In countries lacking hip follow-up programs, hip dislocations may be detected at a later period in CP patients. It should be noted that mortal complications may potentially develop in these patients after hip surgery. We presented this case report to put emphasis on these rare but serious complications.
Keywords: Cerebral Palsy, Hip Dislocation, Hypovolemic Shock, Mortal Complication
Introduction
Hip problems are frequently seen in children with cerebral palsy (CP). Large scale research has shown that approximately 1 in 3 children with CP experience hip dislocation (HD) [1, 2]. The rate of developing HD has been found to be correlated with an increase in the severity of the gross motor function classification system (GMFCS) [3].
In these patients, early diagnosis and treatment are crucial for a better clinical outcome and reduced dependency on surgical intervention. CP patients have a higher likelihood of experiencing complications during hip surgery [4]. However, patients who have died due to post-operative complications have rarely been reported in the literature. In this article, we present a child CP patient who died due to complications arising after hip surgery.
Case Report
A 7-year-old GMFCS-5 male CP patient did not have proper hip follow-up due to familial reasons. 3 months prior to surgery, the family applied to a physiotherapist and were referred to an orthopedist for surgical intervention after the examination revealed a potential hip dislocation.
The patient had received surgical treatment in another hospital due to a bilateral hip dislocation (Figure 1). An iliac and proximal femoral derotation-varisation osteotomy was applied to the patient’s right hip (Figure 2). The patient was discharged on the post-operative 2nd day, but was transferred to our pediatric emergency service 1 day later due to clinical deterioration. Based on the evaluations, the patient was admitted to the intensive care unit with a provisional diagnosis of pulmonary embolism, gastrointestinal bleeding, and hemorrhagic shock. An endoscopy was subsequently performed, and hemorrhagic shock due to gastrointestinal system bleeding was considered. Despite all treatment efforts, the patient did not respond to cardiopulmonary resuscitation and died on the 3rd day of intensive care unit admission due to cardiac arrest.
Discussion
Studies have reported that CP patients who undergo surgery more commonly experience complications such as avascular necrosis of the femoral head, recurrent hip dislocation, femur fracture, aspiration pneumonia, neurological complications, and infection at the wound site [4]. In the literature, a clinical trial with 79 CP patients reported that 3 died due to complications following hip surgery [5]. Of these patients, 2 died on the post-operative 2nd week and 1 died 5 months later [5]; however, our patient developed mortal complications on the post-operative 1st week. In a study involving CP patients who underwent orthopedic surgery, Lee and colleagues reported that 3 patients went into peri-operative cardiac arrest and were resuscitated[6]. The early detection of hip problems in CP children will reduce dependency on surgical intervention and help prevent potential complications of surgery. In Europe, Australia and Canada, hip follow-up programs have increased the rates of early diagnosis and reduced the dependency on surgical treatment. In countries lacking routine hip follow-up programs, individuals with an increased risk of hip dislocation, especially GMFCS-5 patients, should be regularly monitored [7]. Anticipating the potential complications will help in preventing or minimizing their occurrence [4, 8]. This article presents a post-operative CP patient who died due to gastrointestinal bleeding.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
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Download attachments: 10.4328.ACAM.22027.pdf
İdris Çoban, Mehmet Fethi Ceylan. Cerebral palsy patient who developed mortal complications following hip surgery: A case report. Ann Clin Anal Med 2024;15(Suppl 2):S67-69
Citations in Google Scholar: Google Scholar
This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/
Osteochondroma: In a rare location inside of the skull
Hakan Şahinoğlu, Sırrı Gürhan Çelen, Murat Baykara
Department of Radiology, Istanbul Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22046 Received: 2023-11-13 Accepted: 2024-01-22 Published Online: 2024-03-29 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S70-72
Corresponding Author: Hakan Şahinoğlu, Department of Radiology, Istanbul Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey. E-mail: drhakansahinoglu@gmail.com P: +90 535 332 66 64 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8094-9109
Osteochondromas are benign bone tumors with a cap of hyaline cartilage. An 80-year-old female patient visited the neurology clinic with a complaint of headache. A calcified, pedunculated mass was detected in the left middle cranial fossa on non-contrast computed tomography images. Osteochondromas should also be considered in the differential diagnosis of intracranial bone lesions.
Keywords: Osteochondroma, Skull, Computed Tomography, Magnetic Resonance Imaging
Introduction
Osteochondromas are benign tumors composed of cortical and medullary bone with an overlying hyaline cartilage cap. Furthermore, they must demonstrate continuity with the underlying parent bone cortex and medulla. They are developmental lesions rather than true neoplasms. The radiologic features of osteochondromas are often pathognomonic and reflect their pathological appearance [1, 2]. Intracranial osteochondromas are relatively rare, representing 0.1-0.2% of all intracranial tumors [1, 3]. The literature consists only of sporadic case reports. We present an uncommon case of osteochondroma in the middle cranial fossa, originating from the sphenoid bone
Case Report
An 80-years old woman visited the neurology clinic complaining of a headache that lasted for 1 month. Neurological examination was unremarkable. On non-contrast computed tomography images, a calcified pedunculated solid mass measuring 18 × 13 × 16 mm located in the left middle cranial fossa was detected (Figure 1). The mass appeared to be continuous with medulla of the underlying bone through a hypodense gap, compatible with cartilage tissue. No change in the characteristics or size of the mass was observed in follow-up CT images. On the non-contrast MRI images, an extra axial mass hyperintense in T1WI and T2WI, and hypointense in SWI was observed, with peripheral hypointense thin (<1 mm) cartilage cap (Figure 2). No peripheral edema was seen. Nearby cerebral parenchyma was minimally displaced. In this case, the mass was considered to be benign and unrelated to the patient’s current complaints. Due to advanced age, chronic conditions and the relative absence of mass effect, the patient was not considered a candidate for surgery. Consequently, pathological confirmation of the diagnosis was not made.
Discussion
Although osteochondromas tend to be benign, there is a slight possibility of around 1% for malignant transformation [2]. The thickness of the cartilage cap seen in MRI helps to assess the possibility of malignant transformation. Cartilage cap thickness of more than 2 cm indicates the possible malignant change [3, 4, 5].
Intracranial osteochondromas may arise at any age with the peak incidence in the third decade [6]. Because of the rare incidence of intracranial osteochondromas, the differential diagnosis with other more commonly found tumors, such as meningioma becomes essential. Differential diagnosis based on radiological findings also include osteosarcoma and other miscellaneous osteomatous lesions. Non-contrast CT scans usually show from hyperdense to isodense mass for meningiomas, and calcification is commonly seen [7].
Meningiomas are extra axial tumors and most common tumor of the meninges. They are typically well-rounded lesions originating from dura mater and characteristically exhibit ‘dural tail’ sign [7]. In this case mass lesion’s origin from bony tissue excludes meningiomas. The mass’ non-progressive nature during the follow-up scans, presence of cartilage cap and typical continuous appearance with the underlying bone medulla suggests osteochondroma to be the most likely diagnosis. Clinical manifestation of intracranial osteochondromas mostly depends on the tumor mass effect and location [8].
Conclusion
In light of the literature and imaging findings, osteochondromas should be included in the differential diagnosis list of intracranial bone lesions.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.
Conflict of interest
None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.
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2. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics. 2000;20(5):1407-27.
3. Venkata RI, Kakarala SV, Garikaparthi S, Duttaluru SS, Parvatala A, Chinnam A. Giant intracranial osteochondroma: A case report and review of the literature. Surg Neurol Int. 2011;2(1):118-2.
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7. Buerki RA, Horbinski CM, Kruser T, Horowitz PM, James CD, Lukas RV. An overview of meningiomas. Future Oncol. 2018;14(21):2161-16.
8. Omalu B, Wiley C, Hamilton R. February 2003: A 53‐year‐old male with new onset seizures. Brain Pathol. 2003;13(3):419-1.
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Aspiration of dental file requiring thoracotomy
Elif Açar 1, Suat Konuk 2, Emine Özsarı 2, Orhan Kayakıran 2
1 Department of Allergy-Immunology, Kayseri Erciyes University Hospital, Kayseri, 2 Department of Pulmonology, Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey
DOI: 10.4328/ACAM.22086 Received: 2023-12-26 Accepted: 2024-04-23 Published Online: 2024-04-29 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S73-75
Corresponding Author: Orhan Kayakıran, Department of Pulmonology, Bolu Abant Izzet Baysal University Hospital, Bolu, Turkey. E-mail: orhankayakiran.7@gmail.com P: +90 538 236 10 11 Corresponding Author ORCID ID: https://orcid.org/0000-0001-8419-7039
Other Authors ORCID ID: Elif Açar, https://orcid.org/0000-0002-4669-5034 . Suat Konuk, https://orcid.org/0000-0002-8240-4775 . Emine Özsari, https://orcid.org/0000-0001-5842-7849
Foreign body aspirations are rare in the adult age group, although they occur in children and patients with impaired swallowing reflexes. Clinical presentation of foreign body aspirations is nonspecific and can mimic many other diseases. Although detailed history and radiological imaging can assist in diagnosis, bronchoscopy holds the most important place in diagnosis. Bronchoscopic methods and surgery are used for the removal of the foreign body after diagnosis. In our case, we addressed foreign body aspiration in an adult patient.
Keywords: Apiration, Thoracotomy, Foreign Body
Introduction
Foreign body aspirations are rare in adults. Diagnosis in these cases relies on history and suspicion of a foreign body, as clinical symptoms are not specific. While radiopaque foreign bodies can be detected in chest X-rays, radiolucent objects may not be visible. Flexible fiberoptic bronchoscopy is often the preferred diagnostic intervention. Once diagnosed, prompt removal of the foreign body is crucial and can be performed using flexible fiberoptic bronchoscopy or rigid bronchoscopy. In rare cases, thoracotomy is applied post-aspiration. The presented case involves a 47-year-old male who aspirated a dental file during a root canal procedure. Despite unsuccessful bronchoscopy, thoracotomy and lower lobe resection were performed.
Case Report
A 47-year-old male, who aspirated a dental file during a root canal procedure, was referred to our clinic with severe cough complaints. Physical examination revealed no pathology. A chest X-ray showed an opaque foreign body, approximately 2.5 cm in length, in the right lower lung lobe (Figure 1). Rigid bronchoscopy under operating room conditions was attempted but unsuccessful in reaching the foreign body. Subsequently, a thoracic CT scan was performed to determine the location, shape, and extraction method of the foreign body (Figure 2). The object was identified in the basal segment of the right lower lung lobe, and a fiberoptic bronchoscopy was performed without success. A decision was made to perform a mini thoracostomy. A needle was extracted from the basal segment of the right lower lung lobe. Postoperative chest X-rays at 1 and 24 hours showed no pathology. The patient had an uneventful recovery and was discharged after one day of intensive care monitoring.
Discussion
Despite advancements in anesthesia techniques today, foreign body aspiration into the airway can still lead to complications, especially in childhood and advanced age, sometimes resulting in fatal clinical scenarios. In the literature, foreign body aspirations in childhood are reported as one of the most significant causes of mortality [4, 5]. In the United States, an average of 300 children is lost annually due to foreign body aspirations [4]. In children, due to the tracheobronchial system being weaker than in adults, foreign bodies entering the respiratory system can cause sudden obstructions [1, 2, 4].
Symptoms in foreign body aspirations can vary; there may be no signs, or sudden irritant cough, wheezing, side pain, and air hunger may occur. Cough is the most common symptom (90%). The triad of wheezing, paroxysmal cough, and air hunger should raise suspicion of foreign body aspiration. Diagnosis in asymptomatic cases can be challenging.
Partially inert substances, when aspirated, can be tolerated for an extended period without symptoms. However, they may later progress distally, leading to chronic inflammatory reactions such as chronic lung infection, bronchiectasis, or destroyed lung, necessitating lung resection. In radiological evaluation, posteroanterior and lateral chest X-rays are the first step. Computed tomography is useful, especially in assessing inflammatory events after obstruction. When the aspirated foreign body is radiolucent, diagnosis becomes challenging. In some cases, direct chest X-rays and bronchoscopy may not be sufficient. In children, the presence of pneumomediastinum without trauma should raise suspicion of foreign body aspiration. In cases with a history of foreign body aspiration but no definitive diagnosis, repeating bronchoscopy and obtaining a computerized thoracic tomography may be appropriate [2].
Sucu and colleagues applied multiple diagnostic flexible fiberoptic bronchoscopies in cases suspected of foreign body aspiration, detecting foreign bodies in 12 out of 21 cases [6]. In our case, there was a complaint of severe cough, and the patient described the aspiration of a foreign body during a dental canal treatment. Strong evidence or high suspicion of a foreign body history is a definite indication for bronchoscopy. In organic foreign body aspirations, the aspirated organic material, due to swelling or fragmentation, can lead to complications and present more severe clinical pictures. Multiple rigid or flexible bronchoscopies may also be necessary in organic foreign body aspirations [7].
Foreign body aspirations in childhood vary from country to country. Gök and colleagues, who performed bronchoscopy on 249 cases suspected of foreign body presence, detected foreign bodies in 132 cases. The extracted foreign bodies were determined to be 20.76% sunflower seeds, 16.15% watermelon seeds, 13.07% sewing needles, 5.38% dry beans, and other food items in smaller percentages [8].
When dealing with shaped metal foreign bodies such as needles and pins, caution is necessary during extraction to avoid damage to surrounding tissues or potential distal displacement. Extraction by an experienced bronchoscopist, preferably in an operating room setting for patient-physician comfort, is more appropriate. Although the primary preference in treatment is rigid bronchoscopy, the choice may change depending on the patient’s condition, the nature and location of the aspirated foreign body, and the experience of the operator. In our case, thoracotomy was preferred as the foreign body could not be removed with rigid or flexible bronchoscopy.
Conclusion
In summary, foreign body aspirations are rare in adults and, as seen in our case, may sometimes necessitate thoracotomy.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Baharloo F, Veyckemens F, Francis C, Biettlot MP, Rodenstein. Tracheobronchial foreign bodies presentation and management in children and adults. Chest. 1999;115(5):1357-1362.
2. Chen C, Lai C, Tsai T. Foreign body aspiration into the lower airway in Chinese adults. Chest. 1997;112(1):129-133.
3. Kaptanoğlu M, Kunt T, Kunt N, Doğan K. Yabancı cisim inhalasyonu: 119 Olgunun Gözden Geçirilmesi [Review of Foreign Body Inhalation: Analysis of 119 Cases]. Türk Göğüs Kalp Damar Cer Derg. 1995;3:78-81.
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5. Fadl F, Omer M. Tracheobronchial foreign bodies: A review of children admitted for bronchoscopy at King Fahd Specialist Hospital, Al Gassim, Saudi Arabia. Ann Trop Pediatr. 1997;17(4):309-313.
6. Sucu N, Aytaçoğlu B, Özgülder A, Köksel O, Gül A, Dikmengil M. Çocuklarda Yabancı Cisim Aspirasyonu: 75 Olguluk Deneyimimiz [Foreign Body Aspiration in Children: Our Experience with 75 Cases]. Türk Göğüs Kalp Damar Cer Derg. 2002;3:155-159.
7. Reugemer J, Perkins J. Combined rigid and flexible endoscopic removal of a BB foreign body from a peripheral bronchus. Int J Pediatr Otorhinolaryngol. 1999;47(1):77-80.
8. Gök Ü, Çelik O, Yalçın Ş, Karlıdağ T, Kaygusuz İ, Çetinkaya T. Pediatrik yabancı cisim aspirasyonları [Pediatric Foreign Body Aspirations]. Fırat Tıp Derg. 1998;1:379-383.
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Bone hydatid cyst resulting in fracture: A rare case report
Hüseyin Akkaya
Department of Radiology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
DOI: 10.4328/ACAM.22160 Received: 2024-02-28 Accepted: 2024-04-19 Published Online: 2024-04-29 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S76-78
Corresponding Author: Hüseyin Akkaya, Department of Radiology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey. E-mail: dr.hsynakkaya@gmail.com P: +90 534 845 42 17 Corresponding Author ORCID ID: https://orcid.org/0000-0001-5821-670X
Hydatid cyst (HC) is a parasitic infestation caused by Echinococcus granulosus that can occur in many parts of the body, most commonly in the liver and secondarily in the lungs. Hydatid cyst accounts for approximately 2-3% of all cases. In this study, we aimed to highlight a 32-year-old male patient with an isolated hydatid cyst in the left femur and the radiological findings of HC. The diagnosis of HC was confirmed pathologically.
Keywords: Hydatid Cyst, Echinococcus Granulosus, Musculoskeletal, Albendazole
Introduction
HC is a parasitic infestation caused by Echinococcus granulosus and humans are an incidental intermediate host for Echinococcus [1]. It is known that most of the infestation affects the liver and lungs [2]. This is because 70% of the cysts drain through the hepatic sinusoids and the rest pass through the lungs[1-3]. Musculoskeletal involvement of hydatid cyst disease may be frequently confused with other lytic/cystic bone lesions. Therefore, it may lead to delayed diagnosis and therefore treatment in cases of musculoskeletal HC. [4]. There is a lack of literature on musculoskeletal hydatid cyst disease suitable for surgical treatment and, to the best of our knowledge, there is no literature on the place of PAIR treatment in bone HC cases. Musculoskeletal HC has been associated with significant morbidity in orthopaedic patients and high recurrence compared to other HC cases [5,6].
The study was carried out in accordance with the provisions of the Declaration of Helsinki and the Good Clinical Practice guidelines. Ethics committee approval was not obtained because the study is a case presentation but oral informed consent was obtained.
Case Report
A 32-year-old male patient presented to the emergency department with a long-standing complaint of pain and swelling in the left thigh and severe pain after a fall. Femur X – ray showed a fracture line in the left femur and a large lytic area in the left femur. The patient with accompanying marked soft tissue swelling was consulted to us for a superficial ultrasound (US) examination with the suspicion of haematoma. US examination revealed a cystic lesion with thick walls and thick septa in the neighbourhood of the left femur [Fig. 1]. Thigh tomography (CT) examination showed a fracture line in the left femoral neck and a lytic area in the proximal left femur [Fig. 2]. Pathological fracture was primarily considered because of the low energy of the trauma and the presence of a large fracture line and large lytic area in the femur with a prominent soft tissue component [Fig. 2]. Magnetic resonance imaging (MRI) of the thigh showed a fracture line with a large lytic area in the left femur and loss of height in the femoral neck [Fig. 3]. It was clearly seen that the lytic area in the left femur was associated with cystic lesions between the neighbouring muscle planes. Multiple cystic lesions with thick walls, some with septa, were observed in the MRI images, the largest of which was 12×5 cm in size in the coronal image [Fig. 3]. This cystic lesion first suggested malignant musculoskeletal cystic lesions. However, in the pathological examination, rock water was found macroscopically and hydatid cyst was diagnosed as a result of Echinococcus granulosus parasites. The patient was hospitalised in the orthopaedic ward and an operation was planned. The patient’s fever rose to 38.6 °C. Laboratory tests showed a normal total WBC count of 5.0 x 109 cells/L, eosinophil level of 236 cells/L and a normal erythrocyte sedimentation rate of 15 mm/hour. Liver function tests were within normal limits and hydatid cyst serology was negative. The patient was prepared for elective surgery with consent and antihelminthic treatment was administered for 5 days preoperatively. The patient underwent surgery under general anaesthesia and the adjacent multiple hydatid cyst lesions and the femur infiltrating components of these lesions were tried to be removed and the femur infiltrating parts were debrided. Careful pericystectomy was performed along the surrounding muscle fibres to remove the mass as a block without perforating the cyst wall. Following excision, a thorough cleaning of the surgical field was performed. Multiple drainage catheters were placed in the surgical bed. Postoperatively, the patient was followed up radiologically and clinically once a month for 3 months and then every 3 months.
Discussion
The majority of hydatid cysts may occur in the liver, lungs or both, but infiltration into muscle and especially bone is considered an unfavourable site[1, 2]. Although the proportion of primary musculoskeletal HC cases is unknown, musculoskeletal involvement is reported to occur in 0.5% to 4% of HC cases [5, 7]. The most common musculoskeletal sites are pelvic, thigh and paravertebral musculature. Liver and lung involvement is very common due to the route of transmission of HC cases to humans. It is theoretically possible that HC can occur anywhere in the body where the blood circulation reaches, especially in endemic countries such as Turkey[8]. It is widely believed that high lactic acid concentration in skeletal muscle and mechanical factors such as contractions reduce sac formation [1, 6]. Localisation, size and stage of the cyst are most important in forming the clinical picture[4]. Since HC can be seen as simple or complex cysts depending on the stage, it can mimic any cyst [6,8]. Bone HC can mimic early-stage osteomyelitis, and in later stages, the cyst gradually grows and fills the medullary space, as in this case. Bone medulla erosion causes osteolysis and can be radiologically confused with lytic bone lesions such as aneurysmal bone cyst, giant cell tumor, and cystic metastasis. Chronic HC cases in which the bone marrow space is extensively invaded by the parasite may mimic fibrous dysplasia. The main reason that makes the diagnosis of hydatid cyst of bone difficult is that it does not have the typical appearance of classical HC. Pericyst formation does not develop in bone hydatid cyst. Because the pericyst is a fibrotic tissue. Therefore, unlike other HC cases, bone hydatid cysts do not calcify (because the calcified area is the pericyst). However, the soft tissue component of the cyst may calcify. In addition, bone HC cases progress along the bone trabeculae and therefore do not form the classic spherical shape [1]. Especially in complicated cases, as in our case, it may not be recognised. It is very important to formulate a surgical plan according to the HC stage and lesion complications and to prevent the shedding of daughter cysts during surgery [3, 5]. The classical treatment of musculoskeletal HC is surgical excision. However, recurrent cysts have been reported in 1-11% of patients after surgery [7]. Albendazole may reduce the recurrence rate of HC disease and is recommended both pre-op and post-op. PAIR treatment in musculoskeletal cases has been increasing in frequency recently [5, 8]. However, PAIR treatment was not considered in our case due to the fact that our case was both disseminated and infiltrated into the bone.
Conclusion
Although musculoskeletal hydatid cysts are extremely rare, they may cause complications depending on the localisation and stage of the lesion. Diagnosis may be difficult and delays in treatment may occur. This case report is one of the few case reports on aspiration cytology of bone involvement. After the diagnosis, appropriate surgical treatment followed by albendazole treatment minimises recurrences.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
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2. Ntombela P, Linda Z, Hlapolosa T, Jingo M. The unsolved problem of musculoskeletal hydatid disease: two case reports. J Med Case Rep. 2023;17(1):531.
3. Sozutok S, Kaya O, Akkaya H, Gulek B. A rare lesion of breast: Hydatid cyst. Malawi Med J. 2022;34(1):68-70.
4. Çakır M, Balasar M, Küçükkartallar T, Tekin A, Kartal A, Karahan Ö, et al. Management of extra-hepatopulmonary hydatid cysts (157 cases). Turkiye Parazitol Derg. 2016;40(2):72-6.
5. Salamone G, Licari L, Randisi B, Falco N, Tutino R, Vaglica A, et al. Uncommon localizations of hydatid cyst. Review of the literature. G Chir. 2016;37(4):180-85.
6. Gürbüz B, Baysal H, Baysal B, Yalman H, Yiğitbaşı MR. Isolated gluteal hydatid cyst. Turkiye Parazitol Derg. 2014;38(3):51-54.
7. Arazi M, Erikoglu M, Odev K, Memik R, Ozdemir M. Primary echinococcus infestation of the bone and muscles. Clin Orthop Relat Res. 2005;432:234-41.
8. Patino JM, Ramos Vertiz AJ. Hydatidosis of the complete humerus. Treated with radical resection and endoprosthesis. Int J Surg Case Rep. 2019;65:296–300.
9. Islami Parkoohi P, Jahani M, Hosseinzadeh F, Taghian S, Rostami F, Mousavi A, et al. Epidemiology and clinical features of hydatid cyst in Northern Iran from 2005 to 2015. Iran J Parasitol. 2018;13(2):310-16.
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Hüseyin Akkaya. Bone hydatid cyst resulting in fracture: A rare case report. Ann Clin Anal Med 2024;15(Suppl 2):S76-78
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Biliary cyst of the paraduodenal bile duct: Report of a case
Soufiane Bigi 1,2, Mohamed Amine Baba 2, 3, 4, Ahmed Kharbach 3, 4, Soukaina Wakrim 1, 2
1 Department of Radiology, Ibn Zohr Agadir University, Hospital of Souss Massa, Agadir, 2 Department of Health, Faculty of Medicine and Pharmacy, Ibn Zohr University, Agadir, 3 Department of Public Health, Faculty of Medicine and Pharmacy, Laboratory of Biostatistics, Clinical Research and Epidemiology, Rabat, 4 Department of Public Health, High Institute of Nursing Professions and Technical Health, Agadir, Morocco
DOI: 10.4328/ACAM.22171 Received: 2024-03-08 Accepted: 2024-05-13 Published Online: 2024-09-11 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S79-81
Corresponding Author: Mohamed Amine Baba, Department of Radiology, Ibn Zohr Agadir University, Hospital of Souss Massa, Agadir, Morocco. E-mail: babamedamine2@gmail.com P: +212 263 344 25 54 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6660-9527
Other Authors ORCID ID: Soufiane Bigi, https://orcid.org/0000-0002-5462-7568 . Ahmed Kharbach, https://orcid.org/0000-0001-6536-5607 . Soukaina Wakrim, https://orcid.org/0000-0001-6536-5607
This work reports the case of a large cyst of the extra hilar common bile duct with a paraduodenal location in a female child, and takes stock of this malformative pathology of the bile ducts which can compromise the patient’s functional hepato-bilio-pancreatic and vital prognosis mainly due to multi organ failure and/or serious septic conditions. The symptoms are generally progressive with the possibility of inflammatory, cirrhotic and neoplastic complications. Surgery is the treatment of choice. This case study sheds light on this malformative pathology in order to become familiar with its clinical and radiological picture as well as its post-therapeutic prognosis.
Keywords: Choledochal Cyst, Biliary, Biliary Liver Cirrhosis, Juvenile Pancreatitis, Bilio-Digestive Anastomosis, Cholangio-MRI
Introduction
Described for the first time in 1723 by VATER, cystic bile duct disease is part of congenital dilatations of the extrahepatic bile ducts [1]. This is a rare, predominantly female condition, which exists before birth since more and more cases are currently diagnosed antenatally during periodic medical visits for pregnancy monitoring. The dilatation is saccular or fusiform in character with or without blockage of biliary drainage. A choledochal cyst is generally suspected in cases of extra hepatic cholestasis in children with triad: mass, pain, and jaundice. Pancreatic and cholangitis are frequently associated with risk of biliary cirrhosis and long-term malignant degeneration, hence the interest in reviewing this entity through this case study in order to acquire the elements necessary to investigate this pathology and prevent its complications. Bile duct cysts (BDC) is a rare congenital disorder, with an estimated prevalence ranging from 1 in 13,500 to 1 in 200,000 live births in Western countries, while the disease is more frequent in Asia [2, 3]. A marked female predominance has been widely recognized (female to male ratio 3:1) [4].
Case Report
This is a 6-year-old girl, with no particular pathological history, admitted for symptoms that had been developing for five days previously, consisting of moderately painful abdominal bloating with pallor. The clinical examination reveals jaundice with abdominal arching next to the right hypochondrium, the flank and the iliac fossa on the same side with sensitivity to palpation, all evolving in a febrile context measured at 38.2°.
The biological assessment reveals cholestasis without hepatic cytolysis, with hyperleukocytosis on the blood count predominantly neutrophils, and normal levels of lipase and amylase.
Ultrasound reveals a cystic formation projecting opposite the arch described above clinically, occupying the area of the hepatic hilum and extending downward to the right iliac fossa, with a thin wall and finely echogenic content, having intimate relationships with the liver and digestive system. The cholangio MRI complement reveals a cystic formation at the expense of the common bile duct with paraduodenal location (extra and intramural portions) compressing the normal lumen of the common bile duct which appears flattened with minimal dilation of the proximal intrahepatic bile ducts and infiltration of fat local peritoneal effusion without significant intraperitoneal effusion. A reflex paralytic ileus is also evidenced by an attraction of the digestive structures towards the right iliac fossa with the appearance of stasis of the intestinal contents. The pancreas and Wirsung are without any abnormality detectable by magnetic resonance. (Figure 1 , 2 and 3).
A laparotomy is performed on the little girl with the establishment of a bilio-digestive diversion by raising the jejunal loop, associated with drainage of the cystic formation (difficulty of resection given the intimate adhesion to the digestive tract and the risk of duodenal wound) and washing of the peritoneal cavity with the release of agglutinated loops.
The operative consequences are simple, marked by regression of the abdominal arch with normal recoloration of the skin and mucosa, resumption of transit and regression of the clinical-biological infectious state.
An MRI check is carried out 6 months and one year after the operation showing a functional bilio-digestive diversion with no sign of hepatic overload and persistence of residual dilatation of the proximal intrahepatic bile ducts. The biology was free of abnormalities during the two checks described above.
Discussion
The common bile duct cyst is the most common malformative cystic anomaly of the bile ducts in children. It is an anomaly detectable after the appearance of suggestive hepatobiliary symptoms or even during pregnancy in the antenatal stage.
The pathophysiology is essentially based on the malformative component of the duodenal intramural junction of the bile and pancreatic ducts, responsible for the erosion of the mucous layer by reflux of bile and pancreatic juice. The flow therefore expands the weakened wall in the zone of mucosal failure and thus forms a pseudo-reservoir whose contents promote compression, concretion and lithiasis pathology as well as superinfection. The evolution revealing the malformation is generally in the inflammatory direction causing pancreatitis or even cholangitis. However, early biliary cirrhosis can set in if the picture is blurred and the risk of malignant transformation is described in the long-term pictures.
A significant association between BDC is unanimously reported with a clear increasing age-related incidence. Cholangiocarcinoma (CC) is the most frequent histological type encountered. The incidence of synchronous CC associated with BDC is estimated to be 2.5–30% [4] and was 6% in the largest reported Western experience [5].
The diagnosis is based on mapping the biliopancreatic ducts using cholangio-MRI, capable of providing a complete morphological assessment of the bile ducts, an analysis of their contents and an evaluation of the nearby local intraperitoneal state. The role of cholangio-MRI is also essential in monitoring patients in the medium and long term to investigate a possible anomaly at the early stage.
The treatment is based on the complete excision of all extrahepatic biliary structures, with the reestablishment of bilio-digestive continuity being ensured by a jejunal anastomosis, either in a Y shape or on the duodenum.
The added value of our case study lies in the dual-component management of the problem. The patient benefited from the implementation of a bilio-digestive diversion, which halted the bile replacement. On the other hand, the drainage of the bulky cystic bile duct dilatation was performed to eliminate the compression exerted by the stagnant bile contents.
Through this case study, it turns out that it is important to screen for malformations of the bile ducts in the antenatal period or before any sign of hepato-bilio-pancreatic call during the first weeks of life, in order to diagnose early cystic choledochal malformations instead of seeing them late at the complication stage.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
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Soufiane Bigi, Mohamed Amine Baba, Ahmed Kharbach, Soukaina Wakrim. Biliary cyst of the paraduodenal bile duct: Report of a case. Ann Clin Anal Med 2024;15(Suppl 2):S79-81
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Acute appendicitis in a vehicle driver after a traffic accident: A case report
Ugur Demir, Hüseyin Kafadar
Department of Forensic, Faculty of Medicine, Medical Harran University, Şanlıurfa, Turkey
DOI: 10.4328/ACAM.22189 Received: 2024-03-21 Accepted: 2024-05-06 Published Online: 2024-06-04 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S82-84
Corresponding Author: Ugur Demir, Department of Forensic, Faculty of Medicine, Medical Harran University, 63510, Şanlıurfa, Turkey. E-mail: ugurdmr81@gmail.com P: +90 414 344 45 26 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3266-2861
Other Author ORCID ID: Hüseyin Kafadar, https://orcid.org/0000-0002-6844-7517
Acute appendicitis after abdominal trauma has rarely been reported in the past on a case-by-case basis. In this article, we present a case of acute appendicitis in a motor vehicle accident driver.
Appendicitis should be considered as a differential diagnosis in emergency department admissions with a history of trauma to the abdominal area and complaints of abdominal pain. Because post-traumatic appendicitis is rare, timely diagnosis is crucial. Clinicians and forensic report preparers should be knowledgeable and aware of the development of post-traumatic acute appendicitis.
Due to the case presented in this article, the literature was reviewed. In cases where appendicitis develops after trauma, It was emphasized that the conditions for establishing causality between the trauma and the outcome should be taken into consideration and that the requested forensic reports should be prepared within this scope.
Keywords: Traffic Accident, Traumatic Appendicitis, Causality
Introduction
Appendicitis is the most common abdominal surgical problem in emergency hospital admissions. It is seen in an average of 7-9% of individuals throughout their lives. Appendicitis often occurs due to obstruction of the appendix lumen. however, trauma has been identified as a rare cause of acute appendicitis [1, 4]. Cases of acute appendicitis after trauma, although rare, have been described in the past [5, 6]. Clinical findings of post-traumatic appendicitis have been reported to be similar to those of non-traumatic appendicitis [3]. Nausea, loss of appetite, fever, and right lower quadrant abdominal tenderness were described as typical findings of appendicitis on admission to the emergency department. Early diagnosis is important in these cases, and medical history and physical examination are required in every case. Ultrasound and tomography imaging are diagnostic methods that support anamnesis and physical examination findings [7]. Diagnosis and treatment of acute appendicitis are similar regardless of its relationship with trauma [6, 7]. Medical history is important in rare cases of post-traumatic appendicitis [2, 3].
In this article, a rare case of appendicitis following an in-car traffic accident, which was referred to us with the request of preparation of a forensic-medical report, is presented.
Case Report
A 65-year-old male patient was admitted to the hospital with a complaint of abdominal pain that started 10 hours after the traffic accident. The patient is a car driver who collided with another car 10 hours before presenting to the emergency room. He stated that he had no pain or medical complaints in his body or abdominal area before, at the time of the accident and in the first 10 hours after the accident. He applied to the hospital 10 hours after the accident with the development of widespread abdominal pain, which was gradual at first, progressively progressing and worsened with movement. In the emergency room examination, defense and rebounding were observed to be positive, and other system examinations were found to be normal. Laboratory values were: white blood cell count (WBC) 11 K/uL, hemoglobin 15.7 g/dL, platelets 321 K/uL. In upper and lower abdomen computed tomography (CT), the diameter of the appendage vermiphoris was measured as 12 mm. It has been stated that the appendix wall is edematous and heterogeneous density increases are observed in the appendiceal periappendicular tissue. No additional abnormalities were detected in the imaging examination. The patient was asked to be examined in consultation with the General Surgery Department. In the serial abdominal examination performed by the General Surgery, it was determined that the defense and rebound positivity continued. Therefore, the patient was taken into surgery and appendectomy surgery was performed. Histopathological examination confirmed the diagnosis of acute appendicitis.
Twenty-two months after the incident, when he applied to the forensic medicine clinic for the preparation of a forensic medical report, he was examined; He stated that his seat belt was fastened at the time of the incident and that he went to the hospital complaining of abdominal pain approximately 10 hours after the traffic accident. During the examination, he was conscious, his system examinations were normal, and a 1×1 cm scar tissue was assigned in the left lower quadrant of the abdomen and a 1×1 cm scar tissue under the umbilicus.
The person did not have any disease before the incident, and after examining all the medical records summarized above, the appendicitis that developed in the person was evaluated as being causally related to the traffic accident that occurred 10 hours ago.
The forensic report was prepared and finalized within this scope.
Discussion
Acute appendicitis after abdominal trauma has been reported rarely in the last century, and it has been stated that the frequency of acute appendicitis reported after trauma is low. [3, 5, 8]. Ciftci et al. (1996) reported appendicitis in only five (0.9%) of 554 patients following abdominal trauma [8]. Salinas-Castro et al. ıt was reported that one person developed appendicitis after trauma to the abdomen with a football ball [7]. Similar to the case of Sharma et al. (1995), our case is similar to seat belt appendicitis in our literature review [6]. However, no cases of appendicitis with a history of acute appendicitis after a traffic accident requiring a forensic report have been encountered. This makes the article important in terms of its contribution to the literature.
There are many causes of acute inflammation of the appendix. Traumatic mechanism is also stated as one of the etiologies defined in the literature [7]. Various anatomical and pathophysiological mechanisms have been proposed as to why the appendix is vulnerable to inflammation following trauma. The first mechanism is that it may be a traumatic external impact involves a process that causes a temporary increase in intra-abdominal pressure, resulting in increased intra-appendiceal membrane pressure. Alternatively, trauma can indirectly cause muscle irritation that causes adhesions or changes in the anatomical position of the appendix, resulting in mucosal edema. In addition, non-direct abdominal trauma may cause edema in the internal organs, restriction of the intra-abdominal space, and therefore increased intra-abdominal pressure [1, 4, 6, 7].
It has been suggested that it may be a direct process that causes appendiceal lumen obstruction by causing abdominal trauma, local edema, inflammation or lymphatic hyperplasia as a different mechanism. [1, 4, 6].
Diagnostic criteria for traumatic appendicitis include the patient having no previous symptoms, the presence of any trauma to the abdominal wall, the first onset of medical complaints 6 to 48 hours after the trauma, and surgical confirmation of appendicitis with persistent/progressive symptoms [7].
In the case presented in this article, all diagnostic criteria for Traumatic appendicitis were met, and appendicitis was detected histopathologically after appendectomy.
Conclusion
The necessity of making a judicial notification and keeping a forensic report in hospital applications that are forensic cases, such as a traffic accident, is known by all medical doctors. The medical consequences that occur after any trauma should also be taken into account when preparing a forensic medical report.
If acute appendicitis is detected in a person after any trauma, a forensic report should be prepared, considering that trauma is a rare cause of acute appendicitis. This situation is emphasized in our case report article.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Khodadadeh P, Achiam M. Trafikuheld som genvej til akut appendektomi [Traffic accident as a shortcut to acute appendectomy]. Ugeskr Laeger. 2012;174(49):3094-3095.
2. Bangs RG. Acute appendicitis following blunt abdominal trauma. Ann Surg. 1992;216(1):100.
3. Toumi Z, Chan A, Hadfield MB, Hulton NR. Systematic review of blunt abdominal trauma as a cause of acute appendicitis. Ann R Coll Surg Engl. 2010;92(6):477-482.
4. Goldman S, Canastra N, Genisca A. Appendicitis Following Blunt Abdominal Trauma: An Illustrative Case. R I Med J. 2022;105(3):37-38.
5. Amir A, Amir L, Waisman Y. Acute appendicitis after a blunt perineal trauma: An illustrative case. Pediatr Emerg Care. 2009;25(3):184-185.
6. Sharma AK, Vig S, Neades GT. Seat-belt compression appendicitis. Br J Surg. 1995;82(7):999.
7. Salinas-Castro KJ, Mejía-Quiñones V, Zúñiga-Londoño NY. Acute appendicitis after closed abdominal trauma: A case report. Radiol Case Rep. 2022;18(2):631-634.
8. Ciftci AO, Tanyel FC, Büyükpamukçu N, Hiçsönmez A. Appendicitis after blunt abdominal trauma: Cause or coincidence?. Eur J Pediatr Surg. 1996;6(6):350-353.
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Ugur Demir, Hüseyin Kafadar. Acute appendicitis in a vehicle driver after a traffic accident: A case report. Ann Clin Anal Med 2024;15(Suppl 2):S82-84
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Chronic foreign body ingestion in two adults with psychiatric disorder: Is it possible to wait and see?
Nuray Colapkulu Akgul 1, Damla Beyazadam 2, Mehmet Sait Ozsoy 3, Orhan Alımoglu 3
1 Department of General Surgery, Gebze Fatih State Hospital, Kocaeli, 2 Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, 3 Department of General Surgery, Istanbul Medeniyet University, Prof Dr Suleyman Yalcin City Hospital, Istanbul Turkey
DOI: 10.4328/ACAM.22190 Received: 2024-03-21 Accepted: 2024-06-12 Published Online: 2024-07-11 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S85-88
Corresponding Author: Nuray Colapkulu Akgul, Department of General Surgery, Gebze Fatih State Hospital, Kocaeli, Turkey. E-mail: nuraycolapkulu@gmail.com P: +90 531 842 53 61 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3033-8702
Other Authors ORCID ID: Damla Beyazadam, https://orcid.org/0000-0001-8678-2004 . Mehmet Sait Ozsoy, https://orcid.org/0000-0003-2935-8463 . Orhan Alımoglu, https://orcid.org/0000-0003-2130-2529
This study was approved by the Ethics Committee of Istanbul Medeniyet University Prof Dr Suleyman Yalcin Sehir Hastanesi (Date: 2023-03-29, No: 2023/0214)
Foreign body ingestion in adults is a rare occurrence; however, intentional ingestion cases are reported among prisoners and individuals with psychiatric disorders. Here, we reported two unusual cases of foreign body ingestion in two adults with psychiatric disorders. A 32-year-old female presented to the emergency department with self-harm to the abdomen to extract a needle under her skin. Radiologic images showed multiple sewing needles in the gastrointestinal tract and adjacent structures. In the other case, a 23-year-old male presented with rectal bleeding after ingesting metallic screws. His previous and new scans revealed multiple metallic screws and safety pins throughout the gastrointestinal tract. Both patients had a history of chronic foreign body ingestion and had never been operated. The aim of this report is to raise a question whether non-operative follow-up could be a treatment of choice after the ingestion of sharp objects such as sewing needles and metallic screws.
Keywords: Foreign Bodies, Eating, Conservative Treatment
Introduction
Intentional or accidental ingestion of a foreign body (FB) is more common in children. However intentional digestions can occur among prisoners and adults with psychiatric disorders [1, 2]. Even though the majority of the ingested bodies can pass through the gastrointestinal tract and leave the body, sharp and pointy objects may cause complications like perforation that can even result in mortality [3]. Controversies exist in the current literature about the management of this entity; and there are advocates on behalf of the endoscopy, immediate surgery and conservative management [4, 5]. Another main concern about the sharp objects is that their ability to migrate to adjacent organs and cause additional complications [4].
To our knowledge, few studies have reported conservative management of sharp object digestion. In this report, we aimed to contribute to the existing literature by presenting the cases of two adults with psychiatric disorder who ingested dozens of sewing needles and metallic screws and had to be managed non-operatively.
Case Report
Case 1
A 32-year-old female presented to the emergency department with a cut on her abdomen. She claimed that there was a needle under her skin and she cut herself with a kitchen knife to extract it. According to her medical records she had bipolar disease and had lots of emergency department admissions with the complaint of abdominal pain. In all admissions, she had left the hospital against medical advice. On physical examination, she had a 4 cm clean cut in the infraumbilical region. On wound exploration, no needle was encountered and the anterior fascia was intact. The wound was cleaned and closed primarily. Vital signs were stable and her abdomen revealed no signs of peritonitis. Her laboratory results were unremarkable. On computed tomography (CT) and plain radiography, there were multiple sewing needles in the abdominal cavity and some of them had migrated into muscles and adjacent structures (Figure 1). In her previous admissions from the last few years, the radiological images were consistent with the current images (Figure 2). After the evaluations of the scans, the patient was advised to be admitted to the surgical ward but she left the hospital against medical advice.
Case 2
A 23-year-old male presented to the emergency department claiming that he swallowed a bunch of metallic screws two hours prior to his presentation. He complained of rectal bleeding and bloody stool. His medical history was significant for schizoaffective disorder. One month ago, he had been admitted to the emergency department with the same complaint and left the hospital against medical advice. His abdomen was soft and no signs of peritonitis were present. On rectal examination, normal stool was detected. His laboratory results were unremarkable. According to his medical records, he had presented before to the emergency department 13 times with hematochezia and metallic screws had been extracted during rectal examination. On a plain radiograph, multiple radiopaque metallic screws were observed along with the whole gastrointestinal tract. On his previous plain radiography 6 months ago, there were additional FBs consisting of a safety pin (Figure 3). The patient was followed up in surgical ward for two days. Hemoglobin levels remained stable and he did not develop any signs of peritonitis. Psychiatric consultant did not consider an inpatient follow-up for the patient. Unfortunately, patient escaped from the surgical ward without completing the follow-up and treatment course.
Ethical Approval
This study was approved by the Ethic Committee of Istanbul Medeniyet University Prof Dr Suleyman Yalcin Sehir Hastanesi (Date: 2023-03-29, No: 2023/0214).
Discussion
Either intentional or accidental, FB ingestion is a frequently seen condition, especially in the pediatric population. Although the majority of FB ingestions in adults are accidental, intentional ingestion is also very common and mostly encountered in patients who have psychiatric conditions [1].
Even though the spontaneous passage of the FB is commonly seen with a rate of 80-90%, ingestion of sharp objects has a high risk of complication such as abscess formation, perforation, hemorrhage, obstruction and death which are documented to be up to 35% [1, 3]. And, complications such as penetration of the FB through the gastrointestinal tract which requires surgical intervention is rare with a rate of less than 1% [1, 3, 4]. Thus, in 10-20% of FB ingestion cases, endoscopic management may be required [3].
Spontaneous passage or complications depend on various factors such as features of the object, duration of ingestion or age of the patient [1]. Sharp or pointy objects such as needles, metallic screws, razor blades are recommended to be extracted endoscopically, especially when found in the stomach or proximal duodenum. According to The European Society of Gastrointestinal Endoscopy Guideline, if the FB cannot be removed endoscopically, daily radiographic follow-up is recommended for sharp-pointed objects and surgical removal must be considered for objects that have passed the ligament of Treitz and fail to leave the gastrointestinal tract within 3 days after ingestion [3].
Along with asymptomatic cases, FB ingestion may cause a wide range of symptoms such as abdominal pain, nausea, vomiting, gastrointestinal bleeding or obstruction [6]. One of our patients is a female with bipolar disorder who had a self-inflicted injury with the aim of extracting the needles she swallowed. Other than her abdominal injury, she had no signs or symptoms caused by the FB. The second patient is a male adult with schizoaffective disorder who had a complaint of rectal bleeding which started 2 hours after ingesting a bunch of metallic screws. Both of the patients had a prior history of several hospital admissions due to FB ingestion.
Plain radiography is the principal method for initial screening for radiopaque objects. However, radiolucent objects such as wood, plastic, bones and thin metal objects may not be detected in plain radiographs. Therefore, CT scan has a much higher sensitivity and specificity for such objects [3]. Both of our cases were evaluated with plain radiographs and CT scans, which revealed the objects in the abdominal cavity and the gastrointestinal tract.
Penetration or migration of the FB to the abdominal viscera is infrequent. Our first case presented multiple sewing needles penetrated into the abdominal cavity and migrated into muscles and adjacent structures. Such complications occur at the sites of angulations within the digestive tract such as upper and lower esophageal sphincter, ileocecal valve and duodenum [3, 6, 7]. In order to avoid such complications, endoscopic or surgical removal of batteries and sharp objects is recommended [3]. However, there are a few conservative approaches reported in the literature for such cases which were managed successfully [6, 8].
Limitation
This report has some limitations. We were unable to reach the patients to investigate whether they required endoscopy or any surgical intervention after leaving our care. Therefore, the subsequent courses of the patients remain unclear.
Conclusion
We reported two uncommon cases of chronic FB ingestion by two patients with psychiatric disorders. Considering the elapsed time period from ingestion to hospital presentation of these two patients, conservative follow-up may be considered with hemodynamically stable patients with no signs of peritonitis.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Wang X, Su S, Chen Y, Wang Z, Li Y, Hou J, et al. The removal of foreign body ingestion in the upper gastrointestinal tract: A retrospective study of 1,182 adult cases. Ann Transl Med. 2021;9(6):502.
2. Blanco-Rodríguez G, Teyssier-Morales G, Penchyna-Grub J, Madriñan-Rivas JE, Rivas-Rivera IA, Trujillo-Ponce de León A, et al. Characteristics and outcomes of foreign body ingestion in children. Arch Argent Pediatr. 2018;116(4):256–61.
3. Birk M, Bauerfeind P, Deprez PH, Hafner M, Hartmann D, Hassan C, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016;48(5):489-96.
4. Dal F, Hatipoglu E, Teksoz S, Ertem M. Foreign body: A sewing needle migrating from the gastrointestinal tract to pancreas. Turk J Surg. 2018;34(3):256–8.
5. Libânio D, Garrido M, Jácome F, Dinis-Ribeiro M, Pedroto I, Marcos-Pinto R. Foreign body ingestion and food impaction in adults: Better to scope than to wait. United European Gastroenterol J. 2018;6(7):974–80.
6. Bezabih YS, Getu ME. Spontaneous passage of accidentally ingested metallic nail in an adult: A case report. Int J Surg Case Rep. 2022;92:106865.
7. Boumarah DN, Binkhamis LS, AlDuhileb M. Foreign body ingestion: Is intervention always a necessity?. Ann Med Surg (Lond). 2022;84:104944.
8. Erbil B, Karaca A, Aslaner A, Ibrahimov Z, Kunt MM, Akpinar E, et al. Emergency admissions due to swallowed foreign bodies in adults. World J Gastroenterol. 2013;19(38):6447–52.
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Nuray Colapkulu-Akgul, Damla Beyazadam, Mehmet Sait Ozsoy, Orhan Alımoglu. Chronic foreign body ingestion in two adults with psychiatric disorder: Is it possible to wait and see? Ann Clin Anal Med 2024;15(Suppl 2):S85-88
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Surgical management of bilateral huge varicose veins of a morbidly obese patient who underwent Bentall procedure thirteen years ago
Baris Akca, Nevzat Erdil
Department of Cardiovascular Surgery, Faculty of Medicine, Inonu University, Malatya, Turkey
DOI: 10.4328/ACAM.22194 Received: 2024-03-25 Accepted: 2024-05-13 Published Online: 2024-07-06 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S89-92
Corresponding Author: Baris Akca, Department of Cardiovascular Surgery, Faculty of Medicine, Inonu University, 44315, Malatya, Turkey. E-mail: baris.akca@inonu.edu.tr P: +90 422 341 06 60 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9154-4764
Other Author ORCID ID: Nevzat Erdil, https://orcid.org/0000-0002-8275-840X
This case presents the management of a morbidly obese risky patient operated for extensive aneurysmatic varicose veins with a history of Bentall procedure for giant ascending aortic aneurysm of 14 cm. The patient had complaints of swelling, discoloration, heaviness, and night cramps in both legs. Physical examination revealed bilateral huge aneurysmatic varicose veins extending medially to knee level, prominent in the anteromedial aspect of both thighs which causes sagging of skin. The patient was using warfarin, and continuous reflux was revealed on left great saphenous vein. No reflux was revealed on the right side. Sequential surgery of legs was performed with 6-month interval starting from the right side. Following an in-hospital preparation period, extensive aneurysmatic dilatations were removed from the skin of both legs, and plastic reconstruction was performed to close the skin incisions. High-risk patients considered inoperable due to comorbidities can treated with detailed preoperative evaluation, good surgical planning and close postoperative follow-up strategy.
Keywords: Obesity, Morbid, Varicose Veins, Warfarin, Aortic Aneurysm
Introduction
Chronic venous insufficiency (CVI) and varicose veins affect a significant part of the population and are encountered by 10-20% of men and 25-33% of women [1]. Varicose veins represent a significant portion of the disease and can notably impact the quality of life by causing a variety of symptoms.
Under normal circumstances, interventions for varicose veins can be safely performed with low risk. In recent years, these interventions have evolved to incorporate minimally invasive methods, eliminating the need for extensive incisions. However, certain patient populations, such as morbidly obese individuals, those with advanced lymphedema, concurrent deep vein thrombosis, patients on anticoagulant therapy, and those experiencing vital organ failures, present an elevated risk of morbidity regardless of the type of intervention performed. Notably, in cases involving widespread and significantly enlarged varicose veins, minimally invasive procedures may not be feasible.
This case presents the management of a morbidly obese patient who was operated for extensive aneurysmatic varicose veins with a medical history of the Bentall procedure operation for a giant ascending aortic aneurysm with a diameter of 14 cm.
Case Report
A morbidly obese, 48-year-old male patient was admitted with complaints of swelling, discoloration, feeling of heaviness, and night cramps in both legs. Thirteen years ago, we performed a Bentall procedure operation for a giant ascending aortic aneurysm with a diameter of 14 cm in our clinic [2]. Therefore, the patient was using warfarin, and the INR level was 2.8 within the therapeutic range. Physical examination revealed bilateral CEAP C4 venous insufficiency with severe aneurysmatic varicose veins of both legs extending medially to the knee level, prominent in the anteromedial aspect of both thighs which causes sagging of the skin (Figure 1(a)). A venous Doppler ultrasound revealed bilateral diffuse aneurysmatic dilatations, no reflux on the right distal extremity and continuous reflux of the left great saphenous vein (GSV). Abdominal ultrasonography didn’t reveal compression or another pathology. The patient was followed up with medical treatment and compression in previous admittance, as the surgery was considered risky. A surgical management decision was taken based on the patient’s current clinical condition. Sequential surgery of legs was planned starting from the right one. The patient was hospitalized preoperatively, warfarin was stopped and low molecular weight heparin (LMWH) was started. Preoperative consultations of cardiology, chest diseases and anesthesia were performed with the preparation of blood and blood products in case of requirement for transfusion. INR levels were measured regularly. The operation was intended to remove the aneurysmatic venous dilatations from the right and left thighs with the skin because of the huge amount of extensive varicose veins and plastic reconstruction of the skin. Also, performing the excision of below knee aneurysmatic venous dilatations via intermittent incisions was planned. Preoperative LMWH treatment was continued until the morning of the operation, and mapping was performed before the operation (Figure 1(a),(b)). The Patient was taken to the operating room with an INR level of below 2.
The patient was operated on general anesthesia. The extensive aneurysmatic venous dilatations of the right thigh which cause sagging of the skin tissue were removed from, and the plastic reconstruction was performed. After careful bleeding control, the layers were closed on the anatomical plane without placing a hemovac drain, which was not deemed necessary. Severe aneurysmatic varicose veins below the knee were completely removed to prevent thrombosis. LMWH and warfarin were started postoperatively. Hematoma, bleeding or infection was not observed in the early period. The patient was discharged with an INR>2. The patient’s complaints were improved one month later (Figure 1(c)).
The left leg’s surgery was performed 6 months later as planned with the same skin incision approach for huge varicose veins (Figure 2 (a), (b)). Following the preoperative mapping of left leg (Figure 2 (b), (c)), the patient was operated with same skin incision and plastic reconstruction technique. Additionally, we performed junctional ligation and division of GSV due to continuous reflux. Below and above-knee aneurysmatic venous dilatations were excised via intermittent incisions. The patient had no complaints with contentment after 12 months follow up from the first surgery, and both legs edema were improved (Figure 3 (a), (b)).
Discussion
CVI and varicose veins involve a wide spectrum of symptoms, and several treatment choices exist for management. Any of these choices is considered correct and appliable [3]. The recommendations for managing symptomatic varicose veins have obviously changed due to the increase of minimally invasive endovascular techniques in the last decade [4]. However, varicose vein disease with or without GSV reflux may have certain differences in the progress and severity, therefore treatment should be specified for the patient [5]. Hence, tailored management should be performe for some complicated cases with multiple comorbidities as in our patient. Superficial venous reflux of this patient treated with conventional junctional ligation and division of GSV and intermittent incisions used for truncal varicose vein treatment. Moreover, extensive aneurysmatic venous dilatations of both thighs which cause sagging of the skin tissue were removed together with skin and plastic reconstruction of skin was performed for both.
This patient and surgeons have avoided a varicose vein surgery for years due to multiple comorbid conditions. As a result, the patient had huge aneurysmatic dilatation of veins, which caused sagging of the skin. Besides the surgical planning, preoperative management of this patient due to multiple comorbidities is also important. Preoperative evaluation should be made in detail and relevant departments should be consulted. INR monitoring should done regularly until the day of surgery and surgery should performed in appropriate conditions. Additionally, it is essential to take the necessary precautions to prevent infection, bleeding, and venous thrombosis in the postoperative period.
In patients with markedly enlarged varicose veins and advanced obesity, the skin experiences stretching due to the expansion of venous vessels. Particularly notable is the occurrence of subcutaneous spaces and skin sagging upon the removal of these enlarged veins, giving rise to potential complications such as infection, hematoma, and cosmetic issues. Consequently, in such instances, the prudent approach involves the removal of superficial veins concomitantly with the skin, employing meticulous planning and suturing techniques to ensure closure without inducing tension.
In this extreme case, the patient exhibited skin sagging attributable to previous overweight conditions and weakened skin associated with enlarged varicose veins. The affected veins were excised in conjunction with the subcutaneous tissues, followed by careful suturing of the subcutaneous and skin layers. Notably, the postoperative period transpired without any discernible complications.
In recent years, minimally invasive methods and mini-phlebectomy have gained popularity and preference in the treatment of varicose veins [1]. However, this approach may not be feasible for certain patients. Particularly in cases involving advanced varicose veins, these enlarged veins need to be excised through specific incisions, and the remaining vessels should be ligated. In a patient who is receiving anticoagulants, as in our case, we effectively managed bleeding by making appropriate incisions and ligating the remaining vessels during operation. We encountered no issues related to bleeding or hematoma during the postoperative period
Conclusion
Patients with chronic venous insufficiency who are at high risk of intervention due to comorbidity and who are considered inoperable can be treated with low morbidity and mortality with detailed preoperative evaluation, good surgical planning and close postoperative follow-up strategy.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Akça B, Erdil N, Çolak M, Dişli O, Yetiş C, Battaloğlu B. Treatment of chronic venous insufficiency with great saphenous vein endovenous radiofrequency ablation and miniphlebectomy in a single session. Turk J Vasc Surg. 2017;26(3):085-090.
2. Battaloglu B, Akca B, Erdil N, Colak C. Right axilloaxillary cannulation for surgical management of a giant ascending aortic aneurysm. J Card Surg. 2018;33(10):679-681.
3. Willenberg T, Sritharan K, Lane TR, Shepherd AC, Davies AH. Management of uncomplicated varicose veins – a case vignette for a clinical decision proposal. Eur J Vasc Endovasc Surg. 2012;44(2):224-226.
4. Gao RD, Qian SY, Wang HH, Liu YS, Ren SY. Strategies and challenges in treatment of varicose veins and venous insufficiency. World J Clin Cases. 2022;10(18):5946-5956.
5. Ihnatovich I, Kandratsenka G, Dabravolskaj J, Ihnatovich K, Novikava N. The multimodal treatment approaches to varicose veins: Preservation versus thermal ablation of the incompetent great saphenous vein. Int J Vasc Surg Med. 2022;8(1): 001-007.
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Baris Akca, Nevzat Erdil. Surgical management of bilateral huge varicose veins of a morbidly obese patient who underwent Bentall procedure thirteen years ago.Ann Clin Anal Med 2024;15(Suppl 2):S89-92
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Geometric phagedenism: A case report
Idris Kurt
Department of Gastroenterology, Kastamonu Training and Research Hospital, Kastamonu, Turkey
DOI: 10.4328/ACAM.22228 Received: 2024-04-21 Accepted: 2024-05-27 Published Online: 2024-07-03 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S93-95
Corresponding Author: Idris Kurt, Department of Gastroenterology, Kastamonu Training and Research Hospital, Kastamonu, Turkey. E-mail: idrisk8607055022@gmail.com P: +90 :554 811 77 10 Corresponding Author ORCID ID: https://orcid.org/0000-0001-5966-1055
Initially termed geometric phagedenism, pyoderma gangrenosum represents a rare, destructive, and highly painful ulcerative lesion affecting the integumentary system. Clinical and pathological manifestations lack distinctiveness. Diagnosis primarily relies on a differential approach, excluding alternative etiologies contributing to the formation of cutaneous ulcers. Given the exclusive reliance on immunosuppressive therapy for Pyoderma gangrenosum, meticulous consideration must be given to excluding other potential causes of ulcerative skin lesions, particularly those stemming from infectious agents where immunosuppression is contraindicated. Frequently, underlying pathologies are implicated, exemplified in our scenario by inflammatory bowel disease. In our study, we present a case involving multiple ulcerated skin lesions. During the evaluation process, we not only diagnosed pyoderma gangrenosum but also identified the underlying etiology as previously misdiagnosed Crohn’s disease. Treatment with anti-tumor necrosis factor (anti-TNF) therapy resulted in complete resolution of the skin lesions and remission of the inflammatory bowel disease.
Keywords: Crohn’s Disease, IBD, Pyoderma Gangrenosum, Ulcerative Lesions of the Skin, Immunsupression
Introduction
Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder marked by pustules that evolve into non-infectious, ulcerative skin lesions. While most occurrences happen spontaneously and are linked to hematologic, rheumatologic, or gastrointestinal conditions, these lesions can also develop at sites of trauma or surgery [1]. It falls under the spectrum of neutrophilic dermatoses, with an incidence of approximately 0.63 per 100,000 individuals. In up to fifty percent of cases, an underlying pathology is identified. There is no pathognomonic feature, necessitating a thorough differential diagnosis (2). We present an intriguing case of inflammatory bowel disease, initially misdiagnosed as ulcerative colitis and subsequently corrected to Crohn’s disease, accompanied by disseminated pyoderma gangrenosum skin lesions. Successful treatment was achieved with anti-tumor necrosis factor (anti-TNF) therapy.
Case presentation
A 63-year-old female patient was admitted to the general surgery ward with acute abdominal symptoms. In addition to abdominal pain, the patient presented with ulcerated lesions localized on the dorsal aspects of the left foot, right shoulder, and vertex of the scalp (Figure 1).
Three months prior to admission, the patient had been diagnosed with ulcerative colitis and was initiated on 5-aminosalicylate therapy. Despite treatment, there was no alleviation of symptoms, including persistent diarrhea (4-5 episodes per day), ongoing abdominal pain, and significant weight loss (~10 kilograms). A physical examination revealed mild abdominal tenderness without signs of rigidity or rebound. Additionally, a perianal fistula with spontaneous drainage was noted. Abdominal computed tomography and perianal magnetic resonance imaging demonstrated thickening of the ileocecal region and the presence of an intersphincteric perianal fistula (Figure 2). Colonoscopy revealed ulceration in the ileocecal region (Figure 3), an internal opening of the perianal fistula in the rectum, and normal mucosa elsewhere in the colon. Biopsies were obtained from the terminal ileum, as well as from the ulcerated skin lesions. Microbiological analyses of the skin lesions and ileal biopsies did not yield evidence of specific microbial pathogens. Histopathological examination of the skin biopsy revealed findings consistent with Pyoderma Gangrenosum (PG), while biopsy of the ileum demonstrated features indicative of active chronic colitis. Following a discussion with the Dermatology department, based on the clinical, radiological, endoscopic, and histopathological findings, the patient was diagnosed with Pyoderma Gangrenosum secondary to perianal fistulizing Crohn’s disease involving the ileocolonic region. Following the initiation of anti-tumor necrosis factor ( Anti-TNF) therapy, the ulcerated skin lesions showed marked improvement (Figure 1), and the patient achieved remission in her Crohn’s disease. Informed consent was obtained from the patient.
Discussion
Pyoderma Gangrenosum, initially referred to as Geometric Phagedenism by Louis-Anne-Jean Brocq, is an infrequent, noninfectious neutrophilic dermatosis characterized by the presence of destructive skin ulcerations [2].
PG histology is non-specific and varies depending on the stage of the lesion. The early observations reveal the presence of a profound suppurative folliculitis characterized by a dense infiltration of neutrophils.The diagnosis relies exclusively on clinical observations and the elimination of other skin conditions that cause ulcers. PG is commonly observed in conjunction with an underlying medical condition, such as inflammatory bowel disease, inflammatory arthritis, hematological illnesses, and solid malignancies, in around 50% to 70% of instances [3].
Approximately 40% of individuals with inflammatory bowel disease (IBD) experience an extraintestinal manifestation of the condition, with the skin being the organ most frequently affected. Common skin manifestations often include erythema nodosum or pyoderma gangrenosum. Pyoderma gangrenosum affects approximately 1-2% of individuals with inflammatory bowel disease (IBD). PG has a yearly occurrence of up to 10 per million and has a tendency to impact women more frequently than men [4].
In our case, the patient was a female with underlying Crohn’s disease, consistent with findings in existing literature. This association between pyoderma gangrenosum and Crohn’s disease has been noted in previous studies, highlighting the importance of recognizing such comorbidities in clinical practice.
The cornerstone of therapeutic intervention lies within immunosuppression, encompassing both topical and systemic modalities. It is imperative to underscore that prior to embarking on the treatment regimen for PG, meticulous exclusion of alternative etiologies is essential. This precautionary measure is paramount due to the contraindication of immunosuppressive therapy in the majority of other etiological factors precipitating cutaneous ulceration [5].
After anti-TNF therapy was initiated, we observed successful healing of the pyoderma gangrenosum ulcerations along with remission of the patient’s Crohn’s disease. This treatment outcome underscores the effectiveness of anti-TNF agents in managing both conditions concurrently, highlighting the potential benefit of this therapeutic approach for patients presenting with this dual pathology.
Conclusion
Pyoderma gangrenosum continues to be an uncommon condition that poses challenges in diagnosis and is seldom encountered by clinicians. Healthcare providers should keep a high level of suspicion, especially in patients with a history of underlying immune conditions, negative culture results, lack of response to antibiotics, or a worsening response to debridement. Timely identification and collaboration with a multidisciplinary team enable proper treatment and help avoid unnecessary procedures.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Binus AM, Qureshi AA, Li VW, Winterfield LS. Pyoderma gangrenosum: A retrospective review of patient characteristics, comorbidities and therapy in 103 patients. Br J Dermatol. 2011;165(6):1244-1250.
2. George C, Deroide F, Rustin M. Pyoderma gangrenosum – a guide to diagnosis and management . Clin Med (Lond). 2019;19(3):224-228.
3. Hobbs MM, Ortega-Loayza AG. Pyoderma gangrenosum: From historical perspectives to emerging investigations. Int Wound J. 2020;17(5):1255-1265.
4. Chakiri R, Baybay H, Hatimi AE, Gallouj S, Harmouch T, Mernissi FZ. Clinical and histological patterns and treatment of pyoderma gangrenosum. Pan Afr Med J. 2020;36:59.
5. Shahid S, Myszor M, De Silva A. Pyoderma gangrenosum as a first presentation of inflammatory bowel disease. BMJ Case Rep. 2014;2014:bcr2014204853.
6. Chen B, Li W, Qu B. Practical aspects of the diagnosis and management of pyoderma gangrenosum. Front Med (Lausanne). 2023;10:1134939.
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Permanent brachial plexus injury after ultrasound guided infraclavicular nerve block in a morbid obese patient: A case report and review of the literature
Emine Ozcan 1, Okyar Altas 1, Zohre Okur 1, Ozgur Yagan 2
1 Department of Anesthesiology and Reanimation, Basaksehir Çam and Sakura City Hospital, Istanbul, 2 Department of Anesthesiology and Reanimation, Faculty of Medicine, Hitit University, Corum, Turkey
DOI: 10.4328/ACAM.22249 Received: 2024-05-05 Accepted: 2024-06-12 Published Online: 2024-07-26 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S96-98
Corresponding Author: Emine Ozcan, Department of Anesthesiology and Reanimation Clinic, Basaksehir Çam and Sakura City Hospital, Istanbul, Turkey. E-mail: dr.emine3419@gmail.com P: +90 530 159 28 56 Corresponding Author ORCID ID: https://orcid.org/0009-0005-2540-7717
Other Authors ORCID ID: Okyar Altas, https://orcid.org/0000-0002-1262-6073 . Zohre Okur, https://orcid.org/0009-0005-9027-0016
Ozgur Yagan, https://orcid.org/0000-0003-1596-1421
This report describes a rare case of permanent brachial plexus injury resulting from ultrasound-guided infraclavicular nerve block in a morbidly obese patient who underwent surgery for a distal radius fracture.
The patient had a body mass index of 61 and experienced chronic pain in the left arm postoperatively, with no improvement in motor function. The EMG results revealed no motor or sensory responses from the left ulnar and median nerves. The patient underwent rehabilitation but suffered from muscle atrophy and bone resorption in the left upper extremity due to chronic loss of motor function. Infraclavicular block can be challenging in obese patients owing to the depth of the nerve plexus and its proximity to the clavicle. Ultrasound guidance and nerve stimulation may enhance the safety and success rate of the procedure. This report discusses the challenges in performing peripheral nerve blocks in obese patients.
Keywords: Brachial Plexus Block, Peripheral Nerve Injuries, Lower Brachial Plexus Neuropathy, Brachial Plexopathy, Costoclavicular Syndrome, Needle-Stick Nerve Injuries, Conduction Blocking Anesthetics
Introduction
Brachial plexus blocks, a widely used anesthetic practice, offer both anesthesia and postoperative analgesia. Compared to general anesthesia, regional anesthesia provides better results when proper surgical conditions and analgesia are ensured. Regional anesthesia is preferred for several reasons, including patient consciousness during surgery, unaltered respiratory function, preserved airway reflexes, and postoperative analgesia. Brachial plexus blocks are particularly beneficial for upper extremity surgeries, as they can prevent potential complications of general anesthesia, such as postoperative respiratory issues in patients with low effort capacity, morbid obesity, sleep apnea syndrome, or gastric aspiration due to vomiting in full patients. The brachial plexus block can be administered at different levels, including interscalene, supraclavicular, infraclavicular, axillary, or midhumeral [1]. Complications may occur after the block, including pneumothorax, hematoma, diaphragmatic paralysis, Horner’s syndrome, dyspnea, chronic pain, infection, local anesthetic systemic toxicity, and nerve injury [2]. In this case report, we present a morbidly obese patient who experienced permanent brachial plexus injury and associated complications following an ultrasound-guided infraclavicular nerve block for distal radius fracture surgery.
Case Report
A 45 years old, 168 cm, male, 173 kg body mass (BMI, 61) underwent surgery at an orthopedic clinic in a different hospital for a left distal radius fracture due to a fall performing ultrasound-guided infraclavicular nerve block in August 2022. The patient had no systemic disease other than hypertension or hypercholesterolemia. A patient who underwent infraclavicular block using USG reported a painful burning sensation in the hand during the procedure. During the 4-hour operation, the patient experienced pain, and the block was performed a second time under USG guidance. The patient did not return motor function to the left arm postoperatively. After the splint was removed 1 month postoperatively, the patient who could not move the fingers of the left hand and lift the arm was referred to the physical therapy and rehabilitation clinic. EMG performed 4 months after the operation showed no motor or sensory responses from the left ulnar and median nerves. The rehabilitation continued with EMG recorded in January 2023, which also showed no changes. The patient was admitted to the hand surgery outpatient clinic of our hospital in March 2023. Necessary examinations were requested with a preliminary diagnosis of brachial plexus injury. During the ongoing rehabilitation process, partial improvement was reported on the April EMG. In May 2023, a moderate response with low amplitude in the 1-2-3rd fingers. Pregabalin 300 mg/day was initiated because of chronic pain. During this period, muscle atrophy, bone resorption, and edema started in the left upper extremity of the patient, who had been immobile for the last 1 year. Stellate ganglion blockade was performed by an algology clinic in an external center, but it did not have a significant effect. A T-score of BMD of 0.415 g/cm2 4.9 (a 40% decrease compared to the contralateral side) on wrist bone densitometry compared to the contralateral side was reported as significantly low and considered as osteoporosis with a high risk of fracture. Physical therapy for patients who still experience pain is ongoing.
Discussion
Infraclavicular block (ICB) offers anesthesia and pain relief for the elbow, forearm, wrist, hand, and fingers [1]. While axillary and supraclavicular blocks can also be used for these procedures, ICB has certain drawbacks such as the block’s depth and proximity to the clavicle. The depth of the block may make it challenging to visualize the nerves, especially in patients with obesity, and may require the use of low-frequency ultrasound. The use of ultrasound guidance, nerve stimulator guidance, or a combination of both can be helpful in performing ICB. Some practitioners opt to use nerve stimulation and ultrasound guidance simultaneously [3]. Nerve stimulation may be employed to confirm needle tip placement in ultrasound-guided IKB, particularly when the ultrasound image is unclear or difficult to obtain due to factors such as obesity or challenging positioning [4]. ICBs are generally safe, with few reported complications. However, complications common to all peripheral nerve blocks, such as nerve injury, bleeding, LA systemic toxicity, and infection, can occur. When performed by experienced specialists with appropriate equipment and under ultrasound guidance, peripheral nerve blocks in obese patients have relatively high block success rates. Nevertheless, obesity may increase the difficulty of performing peripheral nerve blocks and is associated with higher block failure rates. Regional anesthesia rarely causes peripheral nerve injuries, which are usually temporary, lasting from days to months. In studies, the incidence of major complications leading to permanent nerve damage was found to be between 0.015% and 0.09 [5, 2]. The Mechanisms include trauma from the infusion needle, hematoma formation, and neurotoxicity from local anesthetics. A clinical evaluation is necessary, which includes assessing symptoms and conducting imaging tests such as MRI, USG, and EMG. Neurological symptoms can range from mild to severe, including sensory or motor loss. In acute-onset painful plexopathy, it can be difficult to differentiate between true weakness and reduced exertion due to pain. Muscle atrophy may not be evident for several weeks, and tendon reflexes may be reduced in weak muscles. Sensory loss usually affects the axillary nerve distribution but may extend to other nerves. EMG is useful in detecting axonal damage in motor nerves, and needle EMG can assess any muscle, making it possible to evaluate the entire plexus. Magnetic resonance neurography is a specialized procedure that visualizes the roots, plexus segments, and peripheral nerves . Ultrasound is more sensitive than conventional MRI for detecting plexus lesions and can provide information about local factors such as nerve edema, thickening, and T2 hyperintensities. It is also used to noninvasively distinguish preganglionic traumatic lesions from postganglionic lesions [6]. The site of injury was determined from neurophysiological measurements and MRI, which matched the distribution of local anesthetic from the nerve block. In our case, the application of clinical doses of local anesthetic resulted in serious and permanent neuropathy. We attribute this to factors such as intraneural injection due to suboptimal USG imaging due to obesity, or repeated block procedures that pose a risk of neural trauma or neurotoxicity of local anesthetics. Treatment for brachial plexus injuries typically involves immediate initiation of physical therapy and rehabilitation, tailored to the individual needs of each patient. Conservative treatment may be attempted if the fascicles are intact and the degenerative process is not permanent. This may involve the use of analgesics, antidepressants, antiepileptic drugs, and membrane stabilizers. In some cases, ketamine and systemic glucocorticoids may also be used . Early evacuation of hematoma within 4 hours can significantly alleviate symptoms. Sensory changes that occur following axillary artery puncture may indicate plexus damage due to hematoma formation as an early sign. Surgery is recommended if the sensory or motor disturbances persist. (excision of the damaged segment and nerve autograft). Figure 1 shows a flowchart of the treatment of brachial plexus injury caused by a nerve block or vessel puncture [7]. To prevent nerve injuries, possessing thorough anatomy knowledge and experience is essential. Avoid deep sedation and encourage patients to report any numbness/paresthesia during nerve block or venipuncture. Major risk factors for neurological damage after a peripheral nerve block include nerve puncture with a block needle and intraneural injection of local anesthetics. High-pressure intrafascicular injections pose a greater risk of nerve damage [8]. If a patient experiences paresthesia or increased injection pressure, the anesthetic injection should be stopped to minimize intrafascicular injections. In this case, the patient reported a burning sensation and pain during the initial injection. Ultrasound, nerve stimulation, and opening injection pressure can be used to detect needle-nerve contact and intraneural needle placement by monitoring needle placement and injection.
Although rare, trophic changes in the bone after a peripheral nerve injury can occur. In this case, bone densitometry and clinical examination revealed severe osteoporosis in the affected limb, which was caused by immobilization following the radius fracture and the absence of rehabilitation due to nerve injury. Patients should be aware of the risk of pathological fractures and take appropriate precautions, including medical treatment with bisphosphonates, calcium, and vitamin D, and the use of a personalized protective splint. Peripheral nerve blocks, though rare, are among the most common disabling complications of anesthesia, with likely underreported incidence due to medical-legal and institutional reputation consequences. This resulted in the patient’s retirement and a 71% disability rate, ending their work life. Acknowledging the psychosocial problems faced by the patient and potential medicolegal challenges faced by the doctor highlights the significance of this issue.
Conclusion
In upper-extremity surgery, brachial plexus blocks are commonly used instead of general anesthesia due to their advantages, particularly in patients with respiratory system pathologies and obesity. Among the various types of peripheral nerve blocks, infraclavicular blocks are frequently used. Although the occurrence is rare, adverse outcomes may arise from inexperience or patient-related comorbidities. Recent years have seen the widespread use of ultrasonography (USG), which has contributed to a decrease in complication rates. However, for morbidly obese patients, USG may not be sufficient to prevent complications and create adequate blocks, as demonstrated in our patient undergoing upper-extremity orthopedic surgery. We suggest that the use of USG-guided nerve stimulators in peripheral nerve blocks may help ensure patient safety and reduce the risk of complications in such cases.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Stav A, Reytman L, Stav MY, Portnoy I, Kantarovsky A, Galili O, et al. Comparison of the supraclavicular, infraclavicular and axillary approaches for ultrasound-guided brachial plexus block for surgical anesthesia. Rambam Maimonides Med J. 2016;7(2):e0013.
2. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ, et al. Major
complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service [published correction appears in Anesthesiology. 2003 Feb;98(2):595. Mercier Frédéric [corrected to Mercier Frédéric J]. Anesthesiology. 2002;97(5):1274-1280.
3. Beh ZY, Hasan MS, Lai HY, Kassim NM, Md Zin SR, Chin KF. Posterior parasagittal in-plane ultrasound-guided infraclavicular brachial plexus block-a case series. BMC Anesthesiol. 2015;15:105.
4. Blanco AFG, Laferrière-Langlois P, Jessop D, D’Aragon F, Sansoucy Y, Albert N, et al. Retroclavicular vs Infraclavicular block for brachial plexus anesthesia: A multi-centric randomized trial. BMC Anesthesiol. 2019;19(1):193.
5. Nielsen KC, Guller U, Steele SM, Klein SM, Greengrass RA, Pietrobon R. Influence of obesity on surgical regional anesthesia in the ambulatory setting: An analysis of 9,038 blocks. Anesthesiology. 2005;102(1):181-187.
6. Upadhyaya V, Upadhyaya DN. Current status of magnetic resonance neurography in evaluating patients with brachial plexopathy. Neurol India. 2019;67(Supplement):S118-S124.
7. Kim HJ, Park SH, Shin HY, Choi YS. Brachial plexus injury as a complication after nerve block or vessel puncture. Korean J Pain. 2014;27(3):210-8.
8. Hadzic A, Dilberovic F, Shah S, Kulenovic A, Kapur E, Zaciragic A, et al. Combination of intraneural injection and high injection pressure leads to fascicular injury and neurologic deficits in dogs. Reg Anesth Pain Med. 2004;29(5):417-423.
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Emine Ozcan, Okyar Altas, Zohre Okur, Ozgur Yagan. Permanent brachial plexus injury after ultrasound guided infraclavicular nerve block in a morbid obese patient: A case report and review of the literature. Ann Clin Anal Med 2024;15(Suppl 2):S96-98
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Intussusception associated with bowel metastasis in a patient with malignant melanoma
Arslan Hasan Kocamaz 1, Ömer Kişi 2
1 Department of General Surgery, Kayseri State Hospital, Kayseri, 2 Department of General Surgery, Faculty of Medicine, Necmettin Erbakan University Konya, Turkey
DOI: 10.4328/ACAM.22356 Received: 2024-08-06 Accepted: 2024-09-09 Published Online: 2024-09-19 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S99-101
Corresponding Author: Arslan Hasan Kocamaz, Department of General Surgery, Kayseri State Hospital, Kayseri, Turkey. E-mail: md.ahkocamaz@gmail.com P: +90 530 967 64 11 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5257-9611
Other Authors ORCID ID: Ömer Kişi, https://orcid.org/0000-0001-8606-2453
Malignant melanoma originates from the malignant transformation of melanocytes, the pigment-producing cells of the body. Primary and metastatic malignant melanomas are rare in the gastrointestinal tract [1]. While melanoma most commonly occurs in the skin, it can also develop in any tissue where melanocytes are present, including the eyes, upper gastrointestinal system, anus, and mucosa of the vagina. It accounts for 3-4% of all cancers [2]. Malignant melanoma is known to cause acute intestinal obstruction through intussusception. In this case, sudden abdominal pain in a patient with routine follow-up for malignant melanoma was found to be due to intussusception secondary to melanoma metastasis, necessitating surgical intervention.
Keywords: Small Intestine, Malignant Melanoma, Intussusception
Introduction
Malignant melanoma is a neoplasm originating from melanocytes in the skin and is known as the most dangerous type of skin cancer. Recent improvements in the early diagnosis and treatment of melanoma have significantly improved the outlook of the disease. However, melanoma’s high risk for metastasis and the presence of treatment-resistant subgroups remain major challenges in managing the disease.
Although primary malignant melanoma of the small intestine is rare, gastrointestinal metastases of cutaneous and ocular melanomas are relatively common [3]. While small bowel metastases in living patients with malignant melanoma are recognized in only about 4% of cases, autopsy studies have shown that the rate of metastases in the small intestine can rise to as high as 60% [4]. We present a case of acute jejuno-jejunal intussusception due to malignant melanoma with intestinal metastasis detected by tomography.
Case Report
A 68-year-old patient, diagnosed with ocular malignant melanoma with skin metastasis 6 years ago, had been undergoing treatment. The patient experienced colicky abdominal pain and bilious vomiting persisting for three days. Physical examination revealed abdominal distension. Oral and intravenous contrast-enhanced abdominal tomography showed wall thickening and obstruction in proximal small bowel loops (Figure 1). Dilatation was observed in bowel loops proximal to this level. The patient was diagnosed with acute small bowel obstruction, and surgical intervention was decided. During surgical exploration, intussusception due to melanoma metastasis was observed in the jejunal wall at 25-30 cm distal to the Treitz ligament (Figure 2). About 30 cm of the small intestine was removed, followed by an end-to-end jejuno-jejunal anastomosis.
Discussion
Intestinal intussusception is commonly seen in young children but is rare in adults [5]. Intussusception in children is generally managed with medical treatment, and surgery is rarely required. Although 90% of intussusception cases in children are idiopathic, 10% are due to triggering conditions, in adults, intussusception is typically caused by an underlying pathology. Meckel’s diverticulum, colon polyps, lipomas, lymphomas, leiomyomas, or carcinoids can cause intussusception in adults. Various radiological findings specific to intussusception can be detected using ultrasonography and tomography. If intussusception leads to a mechanical small bowel ileus in adults, surgical resection is preferred [6]. The aim of this case presentation is to emphasize that while intussusception is rare in adults, it should always be considered if the patient has a diagnosis of malignant melanoma, as secondary intussusception may occur.
Malignant melanoma is the most common type of metastatic tumor in the bowel. In a study by Branum, 102 cases of small bowel or colon metastasis were found among 6000 melanoma patients. In 27% of patients with bowel involvement, obstruction or intussusception developed. The life expectancy after surgical metastasis resection was found to be significantly higher compared to patients receiving only palliative chemotherapy [7].
Conclusion
Malignant melanoma tends to metastasize to the bowel. In melanoma patients with bowel symptoms, tomography can be used to assess the extent of bowel metastases. Bowel intussusception due to bowel metastasis may present as a complication of malignant melanoma. Although intussusception is rare in adults, secondary intussusception in adults with a diagnosis of malignant melanoma should be considered in patients with appropriate clinical findings. In such cases, surgical intervention and resection may be necessary.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Kulahci O, Turan G. Primary and Metastatic Malignant Melanomas of The Digestive System. Selcuk Med J. 2020;36(4):300-306.
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Integrated treatment for camptocormia, parkinson’s disease and bruxism: A case report
Elisa Calisgan 1, Betül Akyol 2, Cristina Frange 3
1 Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Kahramanmaras Sutcu Imam University, Kahramanmaras,Turkiye, 2 Department of Physical Education and Sport, Faculty of Sport Science, Inonu University, Malatya, Turkiye, 3 Department of Neurology and Neurosurgery, Federal University of Sao Paulo (UNIFESP); Sleep Physio, São Paulo, Brazil
DOI: 10.4328/ACAM.22384 Received: 2024-08-23 Accepted: 2024-09-30 Published Online: 2024-10-19 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S102-106
Corresponding Author: Elisa Calisgan, Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkiye. E-mail: elisacalisgan@ksu.edu.tr P: +90 534 246 24 71 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4710-9540
Other Authors ORCID ID: Betül Akyol, https://orcid.org/0000-0002-3836-1317 . Cristina Frange, https://orcid.org/0000-0002-5435-3579
One of the most common symptoms of Parkinson’s disease (PD) is abnormal posture. Camptocormia, which is rarely observed in patients with PD described the extreme forward-bending trunk position known as “bent spine syndrome”, a condition in which the trunk flexes abnormally when standing or walking but disappears in the supine position. This clinical case includes a 73 year-old male patient diagnosed with PD and sleep bruxism bruxism, presenting Camptocormia, symptoms of tremor, back pain, rigidity, bradykinesia, postural instability, limited mouth opening, decreased facial expression, and fatigue. Width of the mouth opening, mobility, functionality, range of motion, fatigue severity, language, speech and swallowing functions, and quality of life were evaluated before and after treatment. In this study, a detailed evaluation of the patient and a physiotherapeutic treatment protocol were created and performed along with pharmacological treatment focused on diminishing pain, improving mouth opening, swallowing functions and the tone of facial muscles, decreasing tone of abdominal muscles and stretching abdominal fascia, strengthening of the back extensor muscles and core muscles, and improving balance.
Keywords: Camptocormia, Physiotherapy, Rehabilitation, Parkinson Disease, Bruxism
Introduction
Parkinson’s disease (PD) is a neurodegenerative disorder that primarily impacts dopaminergic neurons in the substantia nigra, leading to a reduction of dopamine in the basal ganglia-thalamocortical circuits. As a result, both motor (i.e., tremor, back pain, rigidity, bradykinesia, postural instability, limited mouth opening, decreased facial expression), and non-motor symptoms such as fatigue and sleep disorders (i.e., sleep bruxism) are observed. PD can also manifest with abnormal postures like Camptocormia, neck dystonia, and dropped head syndrome. The evaluation criteria for Camptocormia are brain CT (Computed Tomography), and MRI (Magnetic Resonance Imaging), blood chemistry and neurological evaluation [1].
Camptocormia, also referred to as a bent spine syndrome, is a major complication of advanced PD. It is known as an abnormal/non-fixed flexion of the thoracolumbar spine, observed on standing or walking, with remission on supine position. The International Parkinson and Movement Disorders Society Study Group defined Camptocormia as a neromuscular disorder, a forward bending angle of >30° [2]. Lower Camptocormia (L1-Sacrum, hip flexion) can be defined as a bending angle of ≥30°, and upper Camptocormia (C7 to T12-L1) as a bending angle of ≥45° [3]. The pathogenesis of Camptocormia is still unknown, but the proposed hypothesis relies on a centrally caused abnormality in systems regulating trunk posture [4], and a primary idiopathic axial myopathy related to trunk dystonia [5]. This imbalance of posture due to the weakness of paraspinal and extensor muscles (massive fatty infiltration of paravertebral muscles) and overactivity of abdominal muscles generates a trunk forward flexion posture, bent knees, flexed elbow and ankle, with increasing risk of falls. Camptocormia designates a forced posture with a forward-bent trunk, which triggers extending the neck which may cause weakness of the extensor muscles of the neck, temporomandibular joint dysfunction and sleep bruxism. Sleep bruxism is a repetitive jaw-muscle activity characterised by clenching or grinding of the teeth and/or by bracing or thrusting of the mandible. In turn, sleep bruxism may change craniocervical posture increasing neck angle [2, 6].
There is no pharmacological treatment for Camptocormia, but frequently used are antiparkinsonian drugs (e.g., levodopa, dopamine agonists, anticholinergics and amantadine) which partly covers the treatment. Non-pharmacological treatment are deep brain stimulation (subtathalamic nuclei), corsets for improving kyphosis, and physiotherapy. The patients, who used deep brain stimulation into subthalamic nucleus, underwent clinical assessment utilizing a continuous waveform width of 60 μs in monopolar stimulation, along with amplitude increments of 0.2-0.5 V at a frequency of 130 Hz [1, 5].
This case report presents a combined physiotherapy management for a patient with concomitant PD, Camptocormia and Sleep bruxism.
Case Report
Patient Information
A male patient, 73 years-old, with Camptocormia (thoracolumbal bending, Figure 1), Hoehn and Yahr Scale range: 1.5-2.5, indicating bilateral involvement without impairment of balance, axial involvement and mild bilateral disease with recovery on pull test, attending the Ataturk University Hospital was invited to participate in the study. Ethical approval was not required. Written patient consent to publication of this case history was obtained.
The patient had comorbid bruxism and presented with spasms in both masseter, orbicularis and trapezius muscles, with complaints of neck and back pain and difficulty opening the mouth due to pain.
Clinical Findings
In laboratory examination, hemogram, erythrocyte sedimentation rate (ESH), liver and kidney function tests, alkaline phosphatase, creatine kinase (CK), calcium, phosphorus, osteocalcin, C-reactive protein (CRP), rheumatoid factor (RF), anti-nuclear antibody (ANA), thyroid function tests (TFT) and parathyroid hormone (PTH) levels were normal. The patient’s Vitamin D (25-OH D3) level was 7.4ng/mL (20-80ng/mL). An endocrinologist was consulted for possible etiological reasons of hipodeficency and vitamin D replacement started. The patient sought consultation with psychiatry to explore potential causes like conversion disorder, exhibited no signs of psychopathology.
Paravertebral muscle electromyography (EMG) was not performed for axial muscle myopathy. There was no clinical sign of myopathy, as diagnosed by the physician, and the resultof MRI was mild radicular involvement at L5-S1 level. Measurement of spine angles were performed through goniometer, and the flexion angle of lower thoracis before treatment was 45.9°, while the flexion angle of upper lumbarvertebrae was 47.3º (Figure 1). Angle of the mouth opening was measured through a mandibular goniometer. Measurement of the mouth opening was performed by the distance of the edges of the frontal incisors using a ruler, and was 5.1 cm at baseline.
Diagnostic Assessment
Evaluation scales were
i) Parkinson Disease Questionnaire (PDQ-39), which assesses how often people with Parkinson’s experience difficulties across 8 dimensions of daily living. PDQ-39 consists of 39 multiple-choice questions, covering patients’ mobility, daily living activities, emotional well-being, societal stigma, social support, cognitive function, communication, and physical impairment. Each dimension’s total score ranges from 0 (indicating no difficulty) to 100 (representing constant trouble). Lower scores are indicative of better health, while higher scores suggest a decline in the quality of life [1];
ii) Fatigue Severity Scale (FSS), a 9-item questionnaire designed to assess fatigue. Each item is rated on a scale from 0 to 7. To determine the overall fatigue level, the total score is divided by 9. A mean score <4 indicates no fatigue, while a mean score ≥4 suggests excessive fatigue [2];
iii) Jaw Restriction Scale (JRS) assess the limitation of the jaw movement, which is very common symptom of bruxism. It consists of items that evaluate everyday mouth function, such as chewing, yawning, swallowing, and smiling. The score is from 0 to 10 for each item, where 0 represents no restrictions, and 10 indicates severe limitations. The overall score ranges from 0 to 80. Score of 0 reflects no jaw restrictions and excellent condition, and a score of 80 signifies complete restriction of jaw movement [2];
iv) Swallow Quality of Life Questionnaire (SWAL-QoL) were used for evaluation of language, speech and swallowing functions, quality of life, and superficial postural situation. The SWAL-QoL measures the impact of a swallowing disorder on a patient’s quality of life, gathering information directly from the patient. It comprises 44 questions that assess various aspects of quality of life. Each question is assigned a score ranging from 1 to 5, with 1 representing “completely correct” and 5 indicating “not at all correct.” As the score increases, it indicates an improvement in swallowing functionality [3].
Therapeutic Intervention
A patient with a nine-year record of PD, who had previously exhibited a positive reaction to levodopa, came for assessment due to progressively incapacitating motor fluctuations and notable camptocormia. This patient underwent pharmacological, which remained unchanged dose after rehabilitation, and non-pharmacologial treatment. Pharmacological included liquid and oral L-DOPA/dopadecarboxylase inhibitor, at dosage of 200/50 mg regularly.
Physiotherapy and rehabilitation happened 4 times a week, during 8 weeks (pre-treatment in one session and post-treatment evaluation in one session), comprising 32 sessions : i) 30 sessions of transcutaneous electrical nerve stimulation please correct: here vertebral region to pain relief. Compex Chattanooga® TENS device was used. A single large passive electrode (258 cm2) and two active electrodes (25 cm2 each) were chosen, totalling 12 electrodes. During the procedure, the passive electrode was positioned on the thoracic region, while the active electrodes were placed on the lumbar paravertebral and multifidus motor points. The device settings consisted of 5 seconds of stimulation followed by 5 seconds of no stimulation, with a frequency of 50 beats per second. The voltage was gradually increased until achieving a level of submaximal contraction. This application protocol was sustained for a duration of 15 minutes; ii) 30 sessions of hot packs on back; iii) 15 sessions of therapeutic ultrasound, frequency 3 MHz, a duration of 5 minutes, on bilateral transversus abdominis and multifidus muscles; iv) 30 sessions of rehabilitation exercises consisting of waist-neck exercises, strengthening of the back extensors, stretching the abdominal fascia, stretching the pectoralis muscles, strengthening the core muscles, balance and walking exercise; v) hands on approach on facial and neck muscles, such as Proprioceptive neuromuscular facilitation exercises (PNF), myofascial release techniques (Figure 2). One hour session was composed of TENS for 15 mins, ultrasound for 5 mins, PNF and myofascial release for 15 mins and 3 of the Rocabado exercises (Figure 2), rehabilitation exercises for 20 mins and hot pack for 5 mins at the end.
He was prescribed a spinal orthosis, Jewett type hyperextension brace. Also, an inelastic 8-shaped bandage applied to the back, with the midpoint of the dorsal apex of the kyphosis. As he could not straighten his back, a rope was passed through the middle point of the bandage, and tied to the waist belt at two points. Thanks to this pull, he perceived to have an upright posture (Figure 3). Elastic exercise bands take the place of elastic rope over time. While the most resistant band is used at the beginning, it is later switched to the band that gives less resistance. The patient was instructed to use the orthosis throughout the day, with the exception of the exercise period and overnight sleep. For the exercise routine, he was directed to wear the 8-shaped corset while maintaining an upright posture.
Follow-up and Outcomes
At baseline, PDQ-39 was 92.08; FSS was 7.00, JRS e was 53; and the score of SWAL-QoL was 48. After treatment, the width of the mouth opening improved from 5.1 cm to 5.8 cm. Measurement of the difficulties in daily living (PDQ-39) decreased from 92.08 to 61.09, indicating improvement of quality of life; limitation of jaw moment improved from 53 to 31, based on JRS. Taken together these observations indicated improved functionality, reduced fatigue, better swallowing functions and enhanced quality of life, after treatment (Table 1).
Following the intervention, significant improvements were observed in the range of motion for both the upper and lower extremities via goniometer. This enhancement contributes to an improved patient posture and functionality, thereby increasing overall capacity (Table 2).
The bending angle of lower thoracic region decreased from 45.9º to 25.4º, while the bending angle of the upper lumbar vertebrae improved from 47.3º to 5.9º (Figure 3).
Discussion
This case report presented a physiotherapeutic and rehabilitation program of treatment, aligned with pharmacotherapy, of a patient presenting with Camptocormia, PD and Sleep bruxism. Schroeteler et al. (4) presented 3 cases in which a high frame walker with forearm support was employed to alleviate back pain and enhance walking distance. Conversely, De Seze et al. (5) applied thoraco-pelvic anterior distraction orthosis and physiotherapy to 15 in patients with Camptocormia, resulting in increased lumbar lordosis, reduced pain, and improved quality of life. Additionally, Ye et al. (6) reported a single case demonstrating the resolution of ambulatory disability and flexion posture on a permanent basis through the use of a cruciform anterior spinal hyperflexion device and back extension strengthening exercises.
Although some camptocormia treatment studies have been presented as case reports, Capecci et al. (7) conducted a single-blind, randomized controlled trial involving 20 patients with Parkinsonism who experienced postural deformities. In their study, 7 patients received tailored postural rehabilitation, and 6 patients received a combination of tailored postural rehabilitation and Kinesiotaping. Similar to our study, they also observed improvements in trunk posture, both in sagittal and coronal angles. However, our study differs from Capecci et al. (7) that was focused on tactile stimulation and postural re-education, while we emphasized stretching of facial muscles and back extensor strengthening exercises. In 2005, Sinaki et al. published a study wherein individuals with spinal osteoporosis were provided with a weighted kypho-orthosis accompanied by exercise. The results demonstrated enhancements in kyphotic posture, body balance, gait velocity, and cadence. It’s important to note that the underlying causes of Camptocormia in spinal osteoporosis and Parkinsonism are different significantly. Their study were focused on individuals suffering from Camptocormia associated with osteoporosis (8). The results similar to those of our study showed enhancements in kyphotic posture, body balance and functionality.
Conclusion
This case report presented a physiotherapeutic approach to Camptocormia, PD and sleep bruxism. The physiotherapy and rehabilitation protocol used demonstrated the effectiveness of therapeutic exercise in enhancing activities of daily living and alleviating motor symptoms associated with PD and Camptocormia and bruxism. As a result, we propose that conservative approaches, like hands-on approach, backpack-wearing or back extensor strengthening exercises should be considered as the initial course of action, conservative treatment, rather than invasive methods such as orthopedic surgery. With the enhancement of posture, the patient improved forward head position, experienced a decrease in muscle imbalance leading to TMJ dysfuncion and probably bruxism, as well as the masseter, hyoid and pterygoid muscles, attributable to the adjustment of the chin posture. We believe that this case report will open a venue in treatment possibilities, being useful in helping clarifying the issue of PD, Camptocormia and Sleep bruxism, alleviating the symptoms for a better quality of life.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Azher SN, Jankovic J. Camptocormia: Pathogenesis, classification, and response to therapy. Neurology. 2005;65(3):355-359.
2. Ohrbach R. Diagnostic Criteria for Temporamandibular Disorders: Assessment Instruments. 2016;15.
3. Finizia C, Rudberg I, Bergqvist H, Rydén A. A cross-sectional validation study of the Swedish version of SWAL-QOL. Dysphagia. 2012;27(3):325-35.
4. Schroeteler FE, Fietzek UM, Ziegler K, Ceballos-Baumann AO. Upright posture in parkinsonian camptocormia using a high-frame walker with forearm support. Mov Disord. 2011;26(8):1560-1561.
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6. Ye BK, Kim HS, Kim, YW. Correction of camptocormia using a cruciform anterior spinal hyperextension brace and back extensor strengthening exercise in a patient with Parkinson disease. Ann Rehabil Med. 2015,39(1):128-132.
7. Capecci M, Serpicelli C, Fiorentini L, Censi G, Ferretti M, Orni C, et al. Postural rehabilitation and Kinesio taping for axial postural disorders in Parkinson’s disease. Arch Phys Med Rehabil. 2014;95(6):1067-1075.
8. Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Significant reduction in risk of falls and back pain in osteoporotic-kyphotic women through a Spinal Proprioceptive Extension Exercise Dynamic (SPEED)program. Mayo Clin Proc. 2005;80(7):849-855.
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Elisa Calisgan, Betül Akyol, Cristina Frange. Integrated treatment for camptocormia, parkinson’s disease and bruxism: A case report. Ann Clin Anal Med 2024;15(Suppl 2):S102-106
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The role of obesity in the development of cardiovascular diseases: An overview of human and rodent studies
Yasemin Hacanlı
Department of Cardiovascular Surgery, Faculty of Medicine, Harran University, Şanlıurfa, Turkey
DOI: 10.4328/ACAM.22062 Received: 2023-12-01 Accepted: 2024-01-08 Published Online: 2024-02-17 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S107-110
Corresponding Author: Yasemin Hacanlı, Department of Cardiovascular Surgery, Faculty of Medicine, Harran University, Şanlıurfa, Turkey. E-mail: yaseminhacan@hotmail.com P: +90 506 700 27 00 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4427-8149
Basically, obesity occurs when the amount of calories taken into the body is more than the amount spent in the long term. Treatments applied by reducing calorie intake and increasing movement do not always give positive results. This is because the etiological elements of obesity and the relationship between these elements have not been fully revealed. Factors that play a role in the emergence of obesity include limitation of movement, diet, genetic factors, smoking, psychosocial factors and insomnia. There are many common factors in the pathogenesis of obesity and CVD. In order to reduce the harmful effects of obesity, researchers are creating animal feeding protocols, especially rodents, and conducting studies that cannot be done on humans. The aim of this review is to briefly address two important interrelated issues that affect human health and life: the relationship between obesity and cardiovascular diseases. The review will also dicuss why rodent models are used.
Keywords: Obesity, Cardiovascular Diseases, Obesity And Rodent Models
Introduction
In general, obesity is the occurrence of excessive fat as a result of the excess fat taken into the body, which creates health problems [1]. This disease is also the basis of cardiovascular diseases (CVD), type 2 diabetes (T2DM), hepatic steatosis, stroke, hypertension and some types of cancer [2].
Obesity was first seen and discussed towards the end of the 16th century [3]. Obesity levels initially appeared in countries with high economic levels. However, today it is a common health problem in countries at all levels of the economy [4]. In essence, obesity is a condition where the long-term calorie intake exceeds the amount of calories consumed by the body.[5]. Treatments applied by reducing the intake of these calories and creating behavioral differences (such as increasing movement) do not always give positive results. This is due to the fact that the etiological elements of obesity and the relationship between these elements have not been fully revealed [6]. Factors that play a role in the occurrence of obesity include limitation of movement, diet, genetic factors, smoking, psychosocial factors and insomnia [7].
Etiology
Obesity, which can start in any age group, occurs with insufficient movement in its etiology and an increase in the consumption of ready-to-eat food. It is due to its intake rather than energy expenditure. In other words, eating foods rich in carbohydrates and high in saturated fat causes obesity. In addition, endocrine disorders can occur due to weight gain triggered by some drugs used and hereditary reasons [8].
Adipose Tissue
In obesity, the stretching feature of adipose tissue is very high. It can even be called unlimited. They are expressed according to their composition, size, function and location. Mammals generally have two types of adipose tissue. White adipose tissue is the most abundant adipose tissue in the body. It can be found around organs and blood vessels in the abdominal cavity and under the skin. The excess energy is preserved in triglyceride structure because the main structure of triglycerides is predominantly composed of glucose. The rate of glucose uptake into adipose tissue is therefore critical in maintaining triglycerides. In addition, this condition plays a role in the likelihood of hypertension and cardiometabolic occurrence [9].
Brown adipose tissue makes up only 4.3% of adipose tissue in an adult human. Axillary, mediastinal, abdominal, paraspinal, cervical and supraclavicular are among the places where it can be found [10]. It has been determined that brown adipose tissue has both cardiometabolic and health-beneficial functions (anti-diabetes, anti-obesity and protection against hypothermia) [11]. In addition, there are interstellar brown fat cells found in newborns, which are deformed over time and are never seen again in adults [12]. A comparison of fat cells in humans and rodents is given in table 1 [13].
Body Mass Index
Body Mass Index (BMI) is a method used to find out if an individual is in a healthy weight range. Calculation of BMI; BMI = Weight (kg)/height2 (m2). Fat accumulation, especially in the middle/abdominal region, is an important health problem. Therefore, better results are obtained from waist circumference and waist-hip ratio calculations. Because waist circumference and waist-hip ratio are related to body fat distribution and central obesity. This relationship is also why it is associated with morbidity (14).
The Relationship Between Obesity and CVD
Obesity is linked to numerous cardiovascular system diseases, including pulmonary hypertension, stroke, and venous thromboembolic disease [16]. There are many common factors in the pathogenesis of obesity and CVD. In both cases, lipids, oxidized LDL particles and free fatty acids activate the inflammatory process, triggering the disease. Inflammation is involved in many processes, from early endothelial dysfunction leading to atherosclerotic plaques and causing complications. Even, it plays a role in the entire process leading to CVD. Adipose tissue releases adipocytokines that induce insulin resistance, endothelial dysfunction, hypercoagulability and systemic inflammation, thereby triggering the atherosclerotic process and other CVDs [17], (Table 3) [18].
Sometimes, obese people may not have any other discomfort other than high BMI. This is called metabolically healthy obesity [19]. It has been proven that people who are metabolically healthy obese (MSO) may develop ‘metabolically unhealthy obesity’ in the future [20].
Discussion
Obesity plays an important role in the development of heart failure with preserved/decreased ejection fraction [21]. Studies have shown that overweight individuals are more likely to develop heart failure than thin patients; It has been proven that this probability is even higher in obese individuals [22]. Likewise, the relationship between the development of atrial fibrillation and obesity has been shown in many recent studies [23]. The tendency of people with MSO towards ‘metabolically unhealthy obesity’ within 4 years was found to be 43% in women and 46% in men. MSO people were also more likely to develop subclinical coronary artery calcifications. These people had a higher incidence of diabetes, CVD, and even death than people of normal body weight [19]. In a large, long-term study involving more than 6,000 individuals and lasting approximately 12.2 years, MSO was compared with metabolically healthy non-obese individuals. Metabolic syndrome was observed to develop in approximately half of MSO individuals [24]. In another study comparing metabolically healthy non-obese individuals with MSO individuals, it was revealed that the likelihood of heart failure, coronary artery disease and cerebrovascular diseases occurring in individuals with MSO was higher [25].
Positive results have been obtained in studies regarding waist/height ratio predicting other diseases, especially CVD [26]. By the European Society of Cardiology; It is recommended that waist circumference be <80 cm in women and <94 cm in men and BMI be between 20-25 kg/m2 [27]. According to another published data results, it has been suggested that waist circumference of 102 cm and above in men and 88 cm and above in women is related to central obesity and may also be linked to Type 2 DM and CVD [28]. In a study, it was suggested that BMI greater than 30 kg/m2, waist/hip ratio and waist circumference pose a CVD threat [29]. In the meta-analysis study conducted by Ashwell et al., it was proven that waist/height ratio is more effective in determining cardiometabolic risks than BMI and waist circumference in both men and women [30].
In short, studies continue to show that regardless of the level of obesity, it increases the likelihood of CVD [31].
Obesity treatment is carried out both in terms of diet, pharmacology and surgery. In terms of diet, weight loss is achieved with a high-fiber, low-fat, low-calorie diet [32]. The main purpose of nutrition is to ensure that the person reaches normal weight ranges. While doing this, CVD events should be eliminated by achieving the appropriate lipid level [33].
In order to reduce the harmful effects of obesity, researchers carry out studies that cannot be performed on humans by creating animal diet protocols, especially on rodents [34]. Because studies on obesity in humans are limited and clear results often cannot be obtained due to accompanying diseases such as hypertension and diabetes [35]. Efforts are being made to create obesity models on animals. However, there is no animal model equivalent to human metabolic syndrome [36].
If rodent models can be constructed in a way that is very similar to human obesity, it supports the view that more information can be obtained [34]. Since obesity plays a major role in the formation of many diseases, various studies have been carried out to reduce its negative effects. When these studies were examined, the protective effects of various chemical substances and extracts obtained from plants with antioxidant and lipid-lowering effects on obesity, especially their functions on heart health, were investigated. These studies include the research conducted on the Andrographolide component of Andrographis paniculata (King of Bitterness), which has been demonstrated to exert a strong anti-obesity effect on the expression of CCAAT/enhancer binding protein β, regulated by protein kinase A (PKA)-CREB (activation of cAMP response element binding protein) in adipogenesis of 3T3-L1 cells [37]. It has been suggested that administration of A. paniculata extracts may also prevent cardiovascular damage by inhibiting the expression of myocardial inflammation and apoptosis-related genes in obese mice fed a high-fat diet [38]. Vieira-Brock et al. fed the mice a high-fat diet (HFD). A mixture of thermogenic food ingredients, including dihydrocapsiate and paprika, alone and in combination with a whey protein supplement, was studied for its effects on body composition in mice. They showed that the mixture stimulated thermogenesis in mice and reduced body weight and fat gain in response to a high-fat diet. These effects have been shown to obtain the same result when applied in combination with whey protein supplementation [39]. In another study, neuroprotective effects were observed by providing green peanut supplementation to mice fed HFD [40]. It has also been proven to improve the lipid profile in obese patients [41].
Conclusion
Based on the information we present in our review, it appears that the likelihood of CVD occurrence increases with the formation and increase of obesity. In this case, threats that induce CVDs need to be either eliminated or reduced. Obesity is one of the main threats. New techniques and methods are needed to control obesity.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and Human Rights Statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Examination of knee sagittal plane movements with wearable sensors and their application to the clinic: A scoping review
Sevtap Cakır, Ozgen Aras
Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey
DOI: 10.4328/ACAM.22117 Received: 2024-01-26 Accepted: 2024-05-13 Published Online: 2024-08-22 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S111-116
Corresponding Author: Sevtap Cakir, Department of Physiotherapy and Rehabilitation, Kutahya Health Sciences University, Kutahya, Turkey. E-mail: sevtap.fzt.26@gmail.com P: +90 534 381 89 27 Corresponding Author ORCID ID: https://orcid.org/0000-0002-4122-3441
Other Author ORCID ID: Ozgen Aras, https://orcid.org/0000-0002-5915-881X
Aim: This study aimed to provide information about knee function by examining sagittal plane movements of the knee with wearable sensors, to summarize the growing literature to determine its clinical applications, and to provide an up-to-date overview.
Material and Methods: We performed a comprehensive search of PubMed, Google Scholar, IEEE, and Scopus databases using various combination of the keywords “knee”, “knee joint”, “wearable technology” and “wearable devices”. We have thoroughly searched the included studies and reference lists to get more devices and references and took the device name and manufacturer for each reference.
Results: It is important for knee-related wearable devices to capture the diversity of knee movements in daily activities. Misalignment of anatomical landmarks and axis of rotation, fast or slow movement, soft tissue artifact, and sensor flexibility can lead to inaccurate measurements.
Discussion: When the studies are examined, there is a rapid growth in this field and accurate and reliable measurements can be made with less error rates. Future studies should determine how to make the most valuable and accurate measurements for patients, reduce sensor complexity, and develop cost-effective models.
Keywords: Wearable Technology, Wearable Devices, Knee and Knee Joint
Introduction
The knee is a frequently injured joint and the frequency of injury is increasing [1]. Clinically significant information obtained by monitoring the kinematic changes of the knee for clinical and research purposes is important for understanding the prognosis of diseases and also for evaluating rehabilitation practice [2]. Evaluation of sagittal plane movements of the knee joint is widely used to evaluate patient function and recovery [3]. This kinematic information is usually obtained with protractors or electro-goniometers and three-dimensional (3D) motion capture cameras. However, electrogoniometers analyze motion in two planes. Three-dimensional motion capture cameras, on the other hand, are considered the gold standard for motion capture, but require a laboratory environment, experienced personnel and cost [4]. Also, it is used only in a limited area, its evaluations are limited to short periods (1-2 hours) and often couldn’t be done because of its high costs [5]. Considering the last ten years, significant progress has been made in the field of wearable technology [6]. Many researchers have developed technologies to assess knee health using wearable sensors, and approaches have focused primarily on sensor detection, knee kinematics or gait assessment [5, 7–9].
Wearable devices, often using magnetometers, accelerometers, and gyroscopes, can provide a higher level of information about joint motion, potentially related to the underlying pathophysiology or rehabilitation condition [5]. Accelerometers are common sensors found in wearable devices and can give acceleration as well as top speed [10]. Jiroscopes are another common sensor in wearable devices that detect angular accelerations [10]. Magnetometers are often combined with and complement accelerometers and gyroscopes to filter the direction of movements [10, 11]. However, İnertial Measurement Unit- based (IMU) approaches must use additional sensing units with accurate computational capability for signal processing and require regular calibration and modeling to reduce the effects of directional drift [12, 13].
The examination of sagittal plane movements of the knee joint seems to be useful for evaluating functionality and medical condition. Studies on sagittal plane movements of the knee have been done [5, 7–9], but the accuracy and reliability of existing devices have not been mentioned. This review aims to provide an up-to-date overview of “”Examination of Sagittal Plane Movements of the Knee with Wearable Sensors and Application to the Clinic”. Using the information in this review, informed and accurate device selections can be made for specific research objectives.
Material and Methods
We conducted a study to examine the movements of the knee in the sagittal plane with wearable sensors and to determine its application to the clinic. Between January 1, 2018 and August 20, 2021, we searched the following databases: PubMed, Google Scholar, IEEE, and Scopus. Due to advances in technology, we did not include older articles in the study.
We have thoroughly searched the included studies and reference lists to get more devices and references. The search strategy included medical topics (i.e. MeSH), terms and text words related to “knee”, “knee joint”, “wearables” and “wearable technology”. We took the device name and manufacturer for each reference.
Ethics Approval
This study is a scoping review of the literature and does not require ethical approval.
Results
The initial search resulted in 2,294 articles and we removed similar ones. We extracted 2,128 more articles based on inclusion and exclusion criteria. Finally, we reviewed the remaining 13 articles to examine the sagittal plane motion of the knee with wearable sensors and to determine their clinical application. A flow chart explaining the identified and included articles is given in articles. Inclusion and exclusion criteria are given below Figure 1.
Inclusion Criteria
• Studies involving the use of any combination of accelerometer, pedometer, or inertial measurement unit for the study of sagittal plane movements of the knee.
• Studies involving a least of n=10 knee patients.
• Works written in English
• Studies whose full text accessed
• Studies that provide accuracy and validity data
Exclusion Criteria
• Conference summaries.
• Book chapters
• Systematic reviews.
• Articles featuring animals, robotic assistive devices, orthoses, exoskeletons, or virtual reality environments
• Primary outcome measures; studies on heart rate, sleep or cognitive/emotional conditions, physical activity level
• Studies that only determine gait parameters and are used as an assistive device during surgery
• Studies describing published study protocols or abstracts.
The purpose, model and manufacturer, technology (sensor) and location characteristics of the studies examined are given in Table 1.
Accuracy and reliability and results of the measurement characteristics of the studies examined are given in Table 2. Limitations of the reviewed studies are given in Table 3.
Discussion
This review provides a comprehensive overview of 13 articles currently available for the study of sagittal plane movements of the knee with wearable sensors, along with hardware features and measurement capabilities (accuracy and reliability), and to determine clinical application.
Continuous and inconspicuously monitoring of kinematic parameters (e.g., range of motion or peak knee flexion/extension angle during the stance phase) can provide important information in determining changes in individuals’ health status and in rehabilitation and/or pharmacological treatments [26]. The use of these systems provides clinicians with the opportunity to closely track the joint healing process and develop personalized, optimal rehabilitation programs to maximize the quality of life of individuals, the main goal of rehabilitation [22]. In addition, the systems provide feedback to the person about their situation, and it is an important support for the participant to reach the predicted goal regarding the quality and completion of the exercises and can also be used to monitor therapy dosage and range of motion throughout the inpatient intervention. At this point, combining sensors with mobile health systems is an important step; however, there is no standard clinical system for continuous knee angle measurement with mobile health devices.
Sensor-based wearable systems should be able to evaluate the individual’s performance not only in rehabilitation outcome and progression, but also during activities of daily living. Because knee movement in daily activities can be highly variable, a sensor system needs to capture the rich variety of knee movements produced during an individual’s daily movement [14]. Büttner et al. [14] showed in their study that the knee angle outputs of the sensor during various activities of daily living were consistent with those of the reference system, and the results were comparable between short- and long-term measurements. Also, non-physiological data outputs were few and sensor failure was not evident. This is promising in that wearable technologies provide accurate results about performance in daily life.
Complex tasks such as jumping are difficult to accurately analyze with wearable sensors due to the large ground impact force. For example, decreased knee flexion during landing from a jump is associated with higher peak moments at the knee joint [27]. It has been stated that MoJoXlab [28] could accurately calculate joint angles for such complex tasks, so it is recommended to be developed to calculate potentially other complex tasks and exercises. Islam et al. [16] also demonstrated that MoJoXlab [28] could use in a clinical setting for complex tasks such as walking, squatting, and jumping, and among a variety of participants, both healthy and participants with anterior cruciate ligament reconstruction.
There are accelerometers, gyroscopes, magnetometers and potentiometers as sensors in wearable devices related to the knee. Allseits et al. stated that the gyroscope is an adequate tool to measure the range of flexion and extension of the knee [20]. On the other hand, Joukov et al. [29] stated that for a complete motion evaluation and effective tracking, an accelerometer, a gyroscope, and a motion capture tracker should be combined in a single tracking unit.
Sensor systems could generally use by being mounted on the knee pad. However, problems such as incorrect palpation of anatomical landmarks or misalignment of the axis of rotation of the sensor during the calibration process have shown that the instrumented knee brace causes larger standard deviations than the reference system. Also, performing the calibration of the knee brace and the sensor with passive knee flexion causes the knee movement to differ in active and weight-bearing conditions such as walking, and this brings with it measurement errors. The elastic material properties of the knee pad can also cause sensor slippage. The stretching of the material may affect the of the actual movements of the legs. Knee angle measurement in terminal flexion and extension is the measurement most affected by this problem. Thus, absolute knee angle data should be interpreted with caution, especially for sagittal knee angle terminal values. However, the deviation value may be less critical as it measures total knee motion angle or changes in total knee angle based on relative data rather than absolute data [14]. All these reasons show that special attention is required for knee pads in which sensors are integrated.
Büttner et al. [14] in their study verbally questioned the adaptations of the participants to the knee brace, and the participants did not report discomfort when wearing an instrumented knee brace during single measurement sessions. Büttner et al. [14] used potentiometer in their study and measured sagittal knee motion during various activities during a mean monitoring time of 7.1 ± 0.8 hours, without any connectivity issues or malfunctions in data transmission.
Accelerometers are sensitive to varying acceleration and vibration modes. However, it can be problematic for mobile applications as it increases bandwidth requirements for mobile systems, and reduces sampling rate and battery life [30]. In measurements made with gyroscopes, it has high accuracy and sensitivity to motion in short measurement periods, while the error rate is high in long measurement periods [17].
Measurement accuracy is an important topic that requires deep research when investigating the diagnostic and evaluation potential of wireless sensors. Again, the repeatability of measurement results is another important factor that determines the validity of wireless sensors. Lisiński et al. [25] showed high reproducibility in the measurement results obtained in both normal and maximum velocity measurements in most of the subjects. Reproducible assessments of the degree of deviation of the knee joint from the flexion and extension trajectory are also very important. All deviations from the knee joint trajectory show possible joint instability [30, 31] or a mismatch of muscle activities affecting the joint [32] and hence the effect of fatigue [33]. Precise motor control and the ability to sense and or show the position of a joint are crucial factors in determining proper knee function. Again, Lisiński et al. [25] evaluated this in their study and evaluated the patients’ ability to return to 60° of flexion and the speed used to reconstruct this angle, and found no significant difference between the results recorded for the left and right knee joint.
The results of most studies presented so far have been considered isolated tests (focusing on a single joint movement) and therefore did not affect the knee joint functions tested. However, in rehabilitation practices, exercises that work several joint and muscle groups are generally used instead of isolated exercises. So, it is also important to test and examine with sensors several global motor tasks that are vital to people’s daily activities, such as sitting in a chair, standing up, lunging forward, and going up and down a step [25]. Lisiński et al.[25] demonstrated successful methods for monitoring exercises performed independently in their studies.
When the oscillating motion in the sagittal plane is rapid, the acceleration measured from the triaxial accelerometer is affected by the effect of gravity and cannot reflect the true flexion angle of the leg [22]. Gholami et al. [18] found that the sensor signal correlated highly with sagittal angles and less with non-sagittal angles. Also, in the same study, knee joint angles were more consistent in participants compared to hip and ankle, providing higher accuracy in estimating knee angles. In addition, soft tissue artifact and sensor limitations affect the estimation accuracy of knee angle in dynamic movements such as walking [19]. One study showed that angles measured during walking, especially at heel strike, have higher error rates than other kinematic parameters. The causes of error during heel strike are related to sensor technology and location and occur because the sensor is not designed to detect hyperextension of the knee joint. For fast speeds also with bigger errors have been reported significant differences in peak flexion angle during both the stance and swing phases [22]. However, Gholami et al. [18] achieved similar accuracy at fast and slow speeds. The flexibility of wearable sensors affects the sensor readings that occur during flexion and extension movements. If the difference in torque and sensor flexibility produced by the person is too low, the sensor torque retraction will be slow and the disparity between flexion and extension will widen. Conversely, high tension can alter gait kinematics or cause stiffness or discomfort by pulling on the skin [22].
Conclusion
As a result; knee angles are often an important outcome measure in the evaluation of biomechanical function for both clinical and research purposes. In many diseases such as stroke and osteoarthritis, abnormal knee flexion/extension patterns can be seen during the gait cycle in patients. Monitoring and tracking these kinematic changes can yield clinically relevant and relevant information and data on prognosis and treatment. This review contains important data on the points to be considered in the measurement of sagittal plane angles of the knee.
What Do We Expect In The Future?
Evaluation of participants’ passive range of motion can provide individualized guidance on the limits to which knee angle data can be expected. Studies have measured not only isolated knee motion but also knee angles with other joints during daily activities, but data on long-term performance are scarce. Future studies should provide long-term follow-up. Reducing the number of sensors in measurements should be the goal of future research to avoid data and statistical complexity. Although the developed sensor devices are quite small and light, velcro straps or an elastic belt are required for skin contact. Converting the hardware to a chip in the future will be an important step in preventing sensor slippage and belt or soft tissue artifact. Again, it is recommended to develop algorithms that prevent soft tissue artifact to improve kinematic tracking. Future work should go towards ergonomic and functional arrangements of smart knee pads that differ in design, structure and material. Modifications are needed to prevent unwanted slack in the sensors, especially during dynamic movements such as running and walking. Again, studies should be carried out to search for a generalizable calibration procedure without the need for any user for sensor calibrations. Finally, advances in technology’s wearability, usability, general appearance and feel, ease of use, time required, and clarity of training will further increase participants’ interest in technology.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Sevtap Cakır, Ozgen Aras. Examination of knee sagittal plane movements with wearable sensors and their application to the clinic: A scoping review. Ann Clin Anal Med 2024;15(Suppl 2):S111-116
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This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/
Spotlight on erythritol as a non-nutritive sweetener: Applications, implications and complications in human health
Syed Imran Ali Shah 1, Mohammed Hussain Alanazi 2, Majed Nidaa Ashammari 2
1 Department of Biochemistry, CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan, 2 College Pharmacy, University of Hafr Al Batin, Hafar Al Batin, Saudi Arabia
DOI: 10.4328/ACAM.22121 Received: 2024-01-19 Accepted: 2024-03-19 Published Online: 2024-06-02 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S117-122
Corresponding Author: Syed Imran Ali Shah, Department of Biochemistry, CMH Lahore Medical College and Institute of Dentistry, Lahore, Pakistan. E-mail: s.shah10@alumni.imperial.ac.uk P: +92 337 142 95 96 Corresponding Author ORCID ID: https://orcid.org/0000-0002-0833-0771
Other Authors ORCID ID: Mohammed Hussain Alanazi, https://orcid.org/0009-0004-2341-9207 . Majed Nidaa Ashammari, https://orcid.org/0009-0009-1176-3867
Non-nutritive sweeteners (NNS) are popular as sugar alternatives. Erythritol, in the last few years, has been extensively used as potentially safe NNS of choice for people with diabetes mellitus and obesity. However, its indiscriminate use has been questioned owing to potential health risks. The present review analysed the physicochemical properties of erythritol and explored the metabolism of erythritol, focusing on pathways of endogenous erythritol synthesis, absorption and elimination. The current work deliberated upon the metabolic impact, gastrointestinal effects and influence on gut microbiota as well as the recent recommendation by WHO against the long term use of erythritol for weight management owing to the potential cardiovascular complications. The need for further research to establish guidelines for the use of erythritol as a NNS is highlighted.
Keywords: Non-Nutritive Sweeteners, Artificial Sweeteners, Low-Calorie Sweeteners, Erythritol, Diabetes Mellitus, Obesity, Weight Management
Introduction
Non-nutritive sweeteners (NNS), also known as artificial sweeteners or low-calorie sweeteners, are sugar substitutes that are used to provide sweetness to foods and beverages without adding calories. They are generally sweeter than table sugar (sucrose), so only small amounts are needed to achieve the desired sweetness [1]. NNS are often used by people who are looking to reduce their calorie intake, manage their blood sugar levels, or simply prefer the taste of sweet foods and beverages [2]. While NNS sweeteners are generally considered safe for consumption, there is ongoing debate about their potential health effects and concerns about their long-term use [3]. Erythritol has gained prominence as a potentially safe NNS; however, despite its advantages and regulatory approval, recent research prompts consideration of potential harmful effects associated with erythritol consumption. This review aims to assess the existing body of literature pertaining to erythritol usage, delineating knowledge gaps and elucidating how comprehensive analyses can contribute to its effective utilization as a NNS.
Material and Methods
In conducting this review, an extensive literature search was performed utilizing the terms “non-nutritive sweeteners” and “erythritol” for a focused exploration of databases, including PubMed, Google Scholar, and Web of Science. Articles with duplicate or redundant content were eliminated through an assessment of their titles. Following the keyword search, data extraction involved examination of the retrieved articles, considering their titles, abstracts, and full texts when necessary to identify pertinent information.
Non-nutritive sweeteners
There are several commonly used NNS, including aspartame, sucralose, saccharin, stevia, neotame, acesulfame potassium and a variety of sugar alcohols. Aspartame is often used in diet sodas, chewing gum, and other low-calorie foods [4]. Sucralose, derived from table sugar (sucrose), is commonly used in diet sodas, baked goods, and other low-calorie foods [5]. Saccharin is one of the oldest NNS and is often used in diet drinks, table sweeteners, and baked goods [6]. Stevia, a natural sweetener derived from the stevia plant, is often used in natural and organic foods, as well as in low-calorie and sugar-free products [7]. Neotame is similar to aspartame and it is often used in baked goods, desserts, and other low-calorie foods [8]. Acesulfame potassium, also known as Ace-K, is used in diet drinks, chewing gum, and other low-calorie foods [9]. Sugar alcohols, also known as polyols, are derived carbohydrates commonly used as artificial sweeteners. They are structurally similar to sucrose but are not fully absorbed in the small intestine, thus they contribute fewer calories and have a lower glycemic index [10, 11]. Xylitol, a sugar alcohol of the five-carbon monosaccharide xylose, is commonly used in sugar-free gum and mints due to its ability to prevent tooth decay. It is also used in baking as a sugar substitute [12, 13]. Sorbitol, a sugar alcohol of glucose, is commonly used in sugar-free candies, chewing gum, and diet drinks [14]. Erythritol, a sugar alcohol of the four-carbon monosaccharide erythrose, is commonly used as a sugar substitute in foods and beverages [13]. Mannitol, a reduction product of mannose, is less commonly used as a sugar substitute due to its laxative effects when consumed in large amounts. It is administered intravenously to reduce intracranial pressure in patients with traumatic head injuries due to its action as an osmotic diuretic [14]. Isomalt, produced from hydrogenation of isomaltulose, is commonly used in sugar-free hard candies, chewing gum, and chocolate. It has a lower glycemic impact than common sugar and does not promote tooth decay [15, 16]. Lactitol is a sugar alcohol derived from lactose and is commonly used as a sugar substitute in chocolate, baked goods, and ice cream [17]. The key chemical characteristics of these sweeteners are summarized in Table 1.
Erythritol
Erythritol is about 70% as sweet as table sugar (sucrose), but has almost no calories and does not raise blood glucose levels in the same way as sugar does [18]. Erythritol is generally recognized as safe (GRAS) by the US Food and Drug Administration (FDA) and is approved for use in many countries around the world [19].
Sources and Synthesis
Erythritol occurs naturally in some fruits, such as watermelon, grapes, and pears, as well as in some fermented foods, such as soy sauce, wine, and cheese [20]. However, the vast majority of erythritol used commercially is synthesized from natural sugars via a fermentation process that involves using specific strains of yeast, such as Moniliella pollinis or Trichosporonoides megachiliensis Yarrowia lipolytica, Aureobasidium and Pseudozyma tsukubaensis. Once the fermentation is complete, erythritol is separated from the fermentation broth via filtration and purification using ion-exchange resins and activated carbon [21, 22]. A small amount of erythritol is also synthesized endogenously in humans through the pentose phosphate pathway (Figure 1) [23].
Physicochemical properties
Erythritol is a four-carbon sugar alcohol or polyol, which belongs to a group of organic compounds called derived carbohydrates. Its chemical formula is C4H10O4, and it has a molecular weight of 122.12 g/mol (Table 1). Erythritol is classified as a tetritol, meaning it contains four carbon atoms. It has a unique molecular structure that consists of four hydroxyl (-OH) groups, with one of the carbon atoms bonded to two of these groups. The remaining two -OH groups are located on the adjacent carbon atoms (Figure 2) [18, 20]. The chemical structure of erythritol gives it several unique properties. Its four hydroxyl groups allow it to bind with water molecules, giving it a cooling effect on the tongue when consumed. It is resistant to fermentation by oral bacteria, which reduces the risk of tooth decay. Erythritol has a white, crystalline appearance and is water-soluble [24, 25].
Digestion and absorption
Erythritol is digested and absorbed differently than regular sugar (sucrose). When consumed, it passes largely unchanged through the digestive system and is absorbed into the bloodstream from the small intestine (Figure 3). Erythritol is passively absorbed through the intestinal wall and into the bloodstream, without the need for digestive enzymes [26]. Only 10% of erythritol is not absorbed and remains available for colonic fermentation and potential production of short-chain fatty acids (Figure 3). Therefore, it does not cause the digestive discomfort that is sometimes associated with other sugar alcohols, such as bloating or diarrhea, when consumed in moderate amounts [13, 25]. Recent studies have demonstrated erythritol to cause a dose-dependent slowing of gastric emptying, increased sense of fullness and stimulation of the release of gut hormones including cholecystokinin (CCK), active glucagon-like peptide-1 (aGLP-1) and peptide tyrosine tyrosine (PYY) [27-29].
Effect on gut microbiota
The intestinal microbiome is crucial for human health as it contributes to metabolism, immunity and growth. It is influenced by diet, and its composition and function can change quickly. Erythritol is neither fermented by gut microbiota nor does its consumption have a substantial impact on it. Erythritol does not produce lactic acid or organic acids when incubated with gut bacteria and it is also non-fermentable by freshly collected human fecal microbiota [30]. In vitro testing of erythritol on gut microbiota representatives also did not show any impact on bacterial growth. However, when tested using a human gut microbial community, erythritol led to an increase in the production of butyric and pentanoic acids which are by products of bacterial fermentation [31].
Metabolism and excretion
Absorbed erythritol reaches the liver through the portal circulation but is minimally metabolized there. Instead, it enters the systemic circulation and is taken to the kidneys for excretion (Figure 3). A dose ranging study has shown a small amount of ingested erythritol to be converted into erythronate which has recently been identified as a product of oxidative stress resulting from metabolic imbalance [32]. A study in murine cell lines has shown erythritol’s ability to protect against non-alcoholic fatty liver diseases (NAFLD) due to its function as an antioxidant, via activation of nuclear factor E2-related factor 2 (Nrf2) signaling pathway which can lead to the inhibition of endoplasmic reticulum stress and hepatic lipid accumulation [33]. Erythritol is primarily excreted from the body via the kidneys without undergoing significant metabolism. The rate of renal excretion of erythritol is dose-dependent, meaning that the more erythritol that is consumed, the more is excreted in the urine. Renal clearance of erythritol has been shown to be nearly 50% that of creatinine, indicating tubular reabsorption of erythritol by the kidney [28].
Effects on human metabolism
Multiple previous studies shown that consumption of artificial sweeteners including erythritol does not have any adverse impact on serum lipid profile [34]. The findings from a murine study suggested that erythritol can effectively mitigate metabolic disorders associated with a high-fat diet by increasing short-chain fatty acids (SCFA) and modulating innate immunity. Consumption of erythritol by mice on a high-fat diet showed a lowering of body weight, improved glucose tolerance, and increased energy expenditure as well as reduced hepatic fat deposition, smaller adipocytes, and improved inflammatory profile in the small intestine. Erythritol supplementation led to higher concentrations SCFA, specifically acetic acid, propanoic acid, and butanoic acid, in the serum, feces, and white adipose tissue, as well as reduced inflammation in the colon, suggesting a potential anti-inflammatory effect [35]. A recent study by Witkowsky et al. investigated the relationship between erythritol and the risk of atherothrombotic disease. They initially conducted untargeted metabolomics studies in a group of patients undergoing cardiac risk assessment and found that elevated levels of erythritol and other polyol sweeteners were associated with a higher risk of major adverse cardiovascular events over a three-year period. This association was subsequently confirmed in independent validation cohorts consisting of stable patients undergoing elective cardiac evaluation. Physiological levels of erythritol were also shown to increase platelet reactivity and promote thrombosis. Ingestion of erythritol was reported to cause significant and sustained increases in plasma erythritol levels, exceeding thresholds associated with heightened platelet reactivity and thrombosis potential [36]. These findings highlight the potential risks associated with erythritol and underscore the need for further investigation into its long-term safety [37].
Glycemic control in diabetes mellitus
Erythritol has been suggested to be beneficial for glycemic control in people with diabetes mellitus. Erythritol has a low glycemic index, thereby it does not cause spikes in blood glucose levels following ingestion, and does not adversely impact insulin sensitivity [38-40]. Furthermore, a study investigating the potential role of erythritol in controlling postprandial blood glucose levels in diabetes mellitus (DM) reported that erythritol administration in diabetic mice demonstrated anti-postprandial hyperglycemic effects. Erythritol was shown to competitively inhibit α-glucosidase, a carbohydrate digestive enzyme, through electrostatic interactions involving specific amino acid residues at the enzyme’s active site [41]. A recent interventional study in streptozocin induced diabetic mice showed that 8 weeks of erythritol administration caused reduction in body weight, fluid and water intake, blood glucose, serum aminotransferases, serum creatine kinase and creatinine. Serum insulin level, lipid profile, glucose tolerance ability and pancreatic β-cell function were also improved [42]. Another study in young mice showed prolonged erythritol consumption had no adverse effect on body weight, composition, or glucose tolerance despite substantially high blood erythritol levels [43].
Anti-oxidant effects
Erythritol has been reported to possess the ability to scavenge free radicals and reduce oxidative stress [44]. A recent study tested erythritol for its antioxidant and glucose-regulating properties. In vitro assays highlighted its radical scavenging activity and inhibition of alpha-amylase and alpha-glucosidase enzymes. Molecular docking confirmed its interaction with these enzymes. Erythritol administered to diabetic rats also resulted in improved glucose tolerance, reduced blood glucose levels, and enhanced antioxidant status [45]. A recent murine study in diabetic models has also shown that erythritol reduced oxidative stress [42].
Weight Management
Erythritol has been used for weight management due to its low caloric value and ability to provide sweetness without contributing to weight gain or obesity. Some studies have shown erythritol to reduce adiposity and weight gain [18, 46, 47]. Additionally, a satiating effect of erythritol has also been documented. Since the sweetness of erythritol is less than sucrose as compared to other NNS which have very high sweetness, erythritol is used at high osmolarity to achieve sweetness to sucrose, which allows it to increase satiety at common doses. Osmolarity modulates satiety-related hormones leading to reduced hunger independently of caloric content [48]. However, owing to the safety concerns raised by findings from recent studies, the World Health Organization (WHO) has advised against the use of NNS for controlling body weight. Recent guidelines state that long-term use of NNS is associated with an increased risk of type 2 diabetes, cardiovascular diseases and mortality [49, 50].
Conclusion
Overall, erythritol is a low-calorie sugar substitute that has minimal impact on metabolism. It does not lead to spikes in blood glucose following ingestion, is not dependent on insulin, and has antioxidant properties. These properties make erythritol a potentially safe NNS for patients with diabetes mellitus. However, recent evidence on long term use of erythritol suggests its association with an increased risk of cardiovascular complications. This prompted WHO to issue a statement advising avoidance of the use of NNS for weight management owing to the concerns of elevated cardiovascular and metabolic risks associated with their long term use. In light of these recent developments, further studies are needed to fully understand the impact of erythritol on human health. There is a dire necessity for adequately powered double-blind, randomized controlled trials to assess the safety and investigate the dual nature of erythritol. In the interim period, caution should be exercised in the consumption of NNS including erythritol.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and Human Rights Statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Foramen magnum variables for forensic identification among Egyptians using computed tomographic scans: A narrative review
Ekramy Elmorsy
Department of Pathology, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia
DOI: 10.4328/ACAM.22229 Received: 2024-04-22 Accepted: 2024-05-27 Published Online: 2024-06-13 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S123-126
Corresponding Author: Ekramy Elmorsy, Department of Pathology, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia. E-mail: ekramy.elmorsy@nbu.edu.sa P: +96 650 127 58 35 Corresponding Author ORCID ID: https://orcid.org/0000-0002-7444-2499
Computed tomography scan analysis via three-dimensional (3D) visualization software can portray bones correctly enough that the technique is currently used for forensic identification and virtual autopsy. Foramen magnum (FM) is the largest skull base foramen with widely used variables in the identification of the sex and stature of the human unidentified bone remains. The current study evaluated the published data for using FM variables for identification among Egyptians using computed tomographic scans. The studies showed the reliability of the variables for sexual dimorphism among Egyptians. However, age identification related data were contradictory. Also, most of the published data was considering adults’ scans with limited data regarding earlier age FM variables. Further studies are recommended to study the variables among bigger sized samples from the different Egyptian provinces. Furthermore, combined studies of different skull base variables with FM variables are expected to improve the robustness and accuracy of the collected data.
Keywords: Computed Tomography, Identification, Foramen Magnum, Egyptians
Introduction
An alternative to conventional caliper-based approaches for gathering anthropological measurements is provided by computed tomography (CT) scans. A CT scan’s sequence of two-dimensional (2D) slices can be joined to create three-dimensional (3D) representations of bones that the user can modify and examine. According to Simmons-Ehrhardt et al. (2019) [1], these axes and their metric qualities can be utilized to produce 3D coordinates for landmarks of interest. These coordinates, as well as the distances and/or angles between them, can be used for a variety of morphometric research. There may be more access to osteological data because the 3D models can be saved and retrieved frequently for quantitative or visual analysis. The wide availability of archived CT data has given the opportunity for osteological analysis studies using the data of large samples of living populations [2].
When compared to manual measurements, CT-based measurement data are more accurate and reproducible, particularly when rendered in 3D [2-4]. Using 3D visualization software for the processing of CT scans can portray bones correctly enough that the technique is currently used for virtual autopsy, surgical planning, and the creation of unique surgical implants [5, 6].
In forensic and anthropological investigations of unidentified individuals, measurements of different bones are frequently used to estimate age, gender, stature, and ethnicity [7]. Research using direct measurements of the skull or CT image-based research have established that the cranium is sexually dimorphic [6, 8, 9]. A substantial mass of soft tissue covers the base of the skull, aiding in the foramen magnum’s protection. Therefore, an intact foramen magnum morphometry aids in identifying a person and distinguishing their gender in situations involving severe trauma, fire, explosions, and other events. Thus, the foramen magnum’s morphometry becomes crucial for human identification [10].
Foramen magnum evaluation for identification of human remains
The largest foramen in the skull is called foramen magnum (FM). It lies in the posterior cranial fossa and is positioned anteromedian. It has oval shape with anteroposterior maximum diameter and broader behind. Meninges, vertebral arteries, the spinal accessory nerve, and the lower end of the medulla oblongata are all located within it [11]. The FM can have several shapes, the most common being oval. Variations in shape are significant because they affect the critical structures that travel through them and because they are useful in different surgical techniques. Due to the possibility of compression on the essential structures passing through it, the dimensions of the FM are clinically significant [12].
Additionally, it has been noted that for condylar resection, a longer anteroposterior dimension of the FM allowed for better contralateral surgical exposure [12]. Numerous publications have focused on the FM’s radiologic and anatomical values. While anatomic values obtained by many authors are almost identical, radiologic values range from one another [13]. When utilized in approximation, the morphometry and characteristics of the FM and occipital bone are strong indications for the diagnosis of sex from both a qualitative and quantitative perspective [14, 15].
However, from a quantitative standpoint, measurements of the FM have been used to develop age estimation indices [16]. The FM reaches adult size rather early in development, in comparison to other skeletal sections, and its dimensions and contour are not affected by any musculature. The size of the FM does not vary markedly with ageing as a result of the nervous system’s early maturity compared to other bodily systems. The occipital bone’s portions are completely united as early as a child reaches the age of five to seven years old with expected non-significant changes in the bone size and FM dimensions in older ages [17].
Egyptian studies of foramen magnum variables for identification
Different studies have been published from Egypt discussing the application of the skull variables in computed tomography scans for personal identification and estimation of sex, age and stature using different parts of the skull. According to available data on Pubmed, Scopus, Web of Science and Google Scholars, Six Egyptian articles have been published regarding the application of FM for Forensic identification among Egyptians (Table. 1).
The maximum length (sagittal diameter) and maximum breadth (transverse diameter) of the FM were the primary characteristics measured in the reported Egyptian studies. The FM’s maximum length was measured along the foramen’s major axis in anteroposterior direction. While FM width was estimated based on the widest transverse diameter of the FM in a perpendicular plane to the maximum length. For measurements of data robustness, measurements of length and width were taken on at least three consecutive axial cross section views that were parallel to the foramen’s plane. Then, using mathematical formulas, the FM area and the FM index (FMI) were determined. The FM area was estimated using two different formulas (Routal and Teixeira formulas), which are based on the estimated FM width and length [Routal et al. (Area 1 = ¼ x π x length x width) and Teixeira formula (Area 2= π x [(length + width)/4]2)] [23, 24]. While FMI was estimated as follows: FM width / FM length x 100 [25].
The best image for the FM scans was selected to be from continuous 5 mm thick slices and parallel to the orbitomeatal line. The shape of the FM was evaluated by the direct visual examination and the shapes were classified into main three types which were; regular shape (including oval, egg, round, tetragonal, pentagonal, hexagonal), irregular A (formed by combination of two different semicircles for the former types), and irregular B which cannot be categorized to the previously mentioned types.
Foramen magnum for sexual dimorphism among Egyptians
Sex estimation data were considered in five studies which concluded that all FM variables were significantly higher in Egyptian males than females to variable extents. There was a conflict regarding the variable with the best sex discriminative value. However, FM area was shown to be the best sex discriminant measurement. Tetragonal shape of FM was the most common in both sexes of the study sample.
The FM index was found to be non-significantly higher in males than in females in Kenawy and Mousa study, which is in accordance with Vinutha et al. Indian study. However, the difference in FMI showed significance between both sexes in other Egyptian studies reported by Slima et al. and Abo El-Atta et al.
According to the published Egyptian data, the range of means FM length and FM width were in males (36.71-36.8, 31.1-31.83mm) and (32.18-35.7, 27.2-30.26mm) in females respectively. These mean range values for both males and females were higher than reported values among Indian [26], English [27], and Turkish populations [28]. However, The Egyptian values were lower than the values reported in Swiss population by Edwards et al. study. The differences among populations can be explained by the anatomical variations of the studied populations due to genetics as well as habits and customs. Moreover, the Egyptian studies showed sex discrimination value for the area of FM, which is in accordance with previously published data by Tambawala et al. [26], Tellioglu et al. [29], and Edwards et al. [30] on different populations.
By discriminant function analysis, Egyptian studies reported overall accuracy of sex prediction value by FM length to range from 59.5 to 65% and for FM (Area 2) to range from 64.2 to 65%. While the estimated overall accuracy for FM width was 61.7-64.5%, the overall accuracy of sex prediction for FM (Area 1) and FMI was 62.5% and 14.2% respectively. These values were higher than those reported by Lopez et al. [31] study for Brazilian population, which showed prediction values of 59.6%, 57.4%, 51.1% and 44.7% for Area2, Area1, FM length and the FM width, respectively. However, Uthman et al. [32] study showed a higher sex prediction value for FM area (69.3%) among Iraqi population.
Foramen magnum for age estimation among Egyptians
Regarding age estimation from FM variables, the studies of Lashin et al. [21] and Saleh et al. [22] that included a total of 300 adults who underwent CT scans reported that there was no statistical correlation between FM measurements and age. However, the study of Kholeif and Radwan [18], with 120 scans with ages ranging from one to 65 years, showed that FM length (FML) decrease and FM width (FMW) increase with aging after the age group of 10-19 years. Subsequently, FM index (FMI) tends to decrease with age with a negative correlation between age and FMI. These studies show that mostly no significance of skull variables diameters on age estimation after the ages of puberty. This can be attributed to the ossification of the occipital bone with increasing age [33]. This coincides with the studies done by Wilk et al. [34], Samara et al. [35] and Moodley et al. [36]. In contrast to the Egyptian study data, Meral et al. [37] reported a larger foramen magnum area among Turkish adults. These contradictory FM data regarding age estimation highlight the role of nutritional and sociodemographic factors on the studies outcomes and revealed the limited role of the FM variables in the estimation of age in the human remains.
Concluding remarks
The current studies showed the importance of FM variables in computed tomography scans as reliable tools for sexual dimorphism among Egyptians. The data regarding the benefit of FM variables in age estimation was contradictory and mostly showed a limited role of FM variables regarding age estimation. Also, most of the published data was considering adult scans with limited data regarding earlier age FM variables. Further studies are recommended to study the variables among bigger sized samples of Egyptian populations from the different provinces of the countries. Aso combined studies of different skull base variables with FM variables are expected to improve the robustness and accuracy of the collected data.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and human rights statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Ekramy Elmorsy. Foramen magnum variables for forensic identification among egyptians using computed tomographic scans: A narrative review. Ann Clin Anal Med 2024;15(Suppl 2):S123-126
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Evaluation of the nasolacrimal canal by computed tomography in patients with septal deviation
Furkan Melih Koçak 1, Nuray Bayar Muluk 2, Mikail Inal 3, Selçuk Baser 4, Ziya Şencan 2, Ela Cömert 2, Gökçe Özel 5
1 Department of ENT, Devrek State Hospital, Zonguldak, 2 Department of ENT, Faculty of Medicine, Kırıkkale University, Kırıkkale, 3 Department of Radiology, Faculty of Medicine, Kırıkkale University, Kırıkkale, 4 Department of Radiology, Kastamonu State Hospital, Kastamonu, 5 Department of ENT, Gökçe Özel Clinic, Ankara, Turkiye
DOI: 10.4328/ACAM.22319 Received: 2024-06-30 Accepted: 2024-08-26 Published Online: 2024-10-09 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S127-132
Corresponding Author: Furkan Melih Kocak, Department of ENT, Devrek State Hospital, Zonguldak, Turkiye. E-mail: drmelihkocak@gmail.com P: +90 507 529 47 93 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4902-6079
Other Author ORCID ID: Nuray Bayar Muluk, https://orcid.org/0000-0003-3602-9289 . Mikail Inal, https://orcid.org/0000-0003-0642-7913 . Selçuk Baser, https://orcid.org/0000-0001-9439-4095 . Ziya Şencan, https://orcid.org/0000-0002-0936-5108 . Ela Cömert, https://orcid.org/0000-0001-7739-2717 . Gökçe Ozel, https://orcid.org/0000-0001-5281-0986
Aim: This study aimed to examine the nasolacrimal canal both proximally and distally in patients with septum deviation, in order to investigate the relationship between septum deviation and nasolacrimal canal diameter and to explore its relationship with maxillary sinus diameter.
Material and Methods: Preoperative paranasal sinus computed tomography images of 50 male and 50 female adult patients who underwent septoplasty were examined, and the deviated side (ipsilateral) and opposite side (contralateral) nasolacrimal canal diameters were measured at the proximal and distal parts. Moreover, bilateral maxillary sinus height, anteroposterior, and horizontal diameters were also measured.
Results: No significant difference was found in the nasolacrimal canal diameter between the ipsilateral and contralateral sides, whether measured proximally or distally (p>0.05). As a result of the measurements, it was observed that the nasolacrimal canal was wider in the proximal part than in the distal part without being affected by the deviation side (p<0.05). Likewise, it was observed that the nasolacrimal canal was wider in males than in females without being affected by the deviation side (p<0.05). Our study revealed no statistically significant differences between the ipsilateral and contralateral MS dimensions (p>0.05).
Discussion: The nasolacrimal canal in men is typically wider than in women; and it tends to be broader at the proximal end compared to the distal end. This anatomical difference may explain why Primary Acquired Nasolacrimal Duct Obstruction is more prevalent in women and why obstruction is frequently observed in the distal part of the canal. Whether septum deviation is one of the etiological factors causing Primary Acquired Nasolacrimal Duct Obstruction is still a controversial issue in the medical community.
Keywords: Septal Deviation, Nasolacrimal Canal, Maxillary Sinus, Primary Acquired Nasolacrimal Duct Obstruction, Paranasal Sinus Computed Tomography
Introduction
Nasal septal deviation is one of the most common anatomical variations observed in the nose [1]. The nasal septum is a structure located in the inner part of the nose, which plays an important physiological role by regulating and supporting the airway. Asymmetrical sloping of the nasal septum to either side is called nasal septal deviation [2]. Possible risk factors for asymmetric growth of the maxillary bone include childhood traumas, as well as genetic and environmental influences [3]. The nasolacrimal canal; is mainly formed by the nasolacrimal sulcus of the maxillary bone. Its cranial and lateral ends are bounded by the lacrimal bone, while its inferomedial end is formed by the lacrimal process of the inferior turbinate [4].
The nasolacrimal canal (NLC) is composed of two parts. The intraosseous superior part is approximately 12 mm long, while the membranous lower part is around 5 mm long. The intraosseous part starts from the floor of the lacrimal fossa. It is bounded laterally by “the maxillary bone, medially by the lacrimal bone, and inferior turbinate” [5]. It opens into the lateral nasal wall, terminating at the Hasner valve in the inferior meatus. In women, the NLC becomes narrower towards the valve of Hasner. Therefore, Primary Acquired Nasolacrimal Duct Obstruction (PANCO) is more common in women [6].
Thin-section axial computed tomography (CT), is an exceptionally effective imaging method for evaluating the lacrimal drainage system and its relationship with surrounding tissues, primarily due to its ability to clearly distinguish contrast differences between soft tissue and bone [4]. This study was undertaken due to the limited number of studies in the literature that examine the relationship between nasal septum deviation, the NLC, and other paranasal anatomical structures.
The NLC was examined both proximally and distally in patients with septum deviation to investigate the relationship between septum deviation and NLC diameter and to reveal its relationship with maxillary sinus (MS) diameter.
Material and Methods
Subjects
This study, conducted retrospectively, involved 50 male and 50 female patients who underwent septoplasty following a diagnosis of septum deviation, and who applied to Kırıkkale University Faculty of Medicine, Kırıkkale Clinic between August 2015 and July 2019. The material of our study consisted of PNS CT images of these patients taken before the septoplasty operation between August 2015 and July 2019 at Kırıkkale University Medical Faculty Hospital, Department of Kırıkkale The individuals within the scope of the study were between the ages of 19-62, and the mean age was found to be 33.86±11.26. There are 32 people in the ≤25 age group, and 68 people in the >25 age group. The side where the septum deviates is referred to as ipsilateral, while the opposite side of the deviation is called contralateral.
Inclusion criteria
The study included patients aged 18 to 75 who had PNS CT images taken before the septoplasty operation with the diagnosis of septum deviation, and there were no signs of nasal polyposis, acute or chronic sinusitis in the CT images examined. PNS CT images of 100 patients in the CT archive were analyzed retrospectively.
Inclusion criteria when selecting images;
• The patient is18 years old or older
• Bilateral nasolacrimal canals are totally in the field of view
• Full inclusion of bilateral maxillary sinuses in the field of view
• Presence of septum deviation
• No nasolacrimal canal obstruction symptoms
Exclusion criteria when selecting images;
• The patient is younger than 18 years old
• Bilateral nasolacrimal ducts or maxillary sinuses are not totally in the field of view
• Image quality does not allow for inspection
• Patients have had a previous operation on the nasolacrimal duct or paranasal sinuses
• Patients with previous septoplasty
• Patients with allergic rhinitis
PNS CT imaging and analysis
All scans were obtained using routine PNS CT imaging in the supine position, without the use of contrast or sedation. The images were captured with a 64-slice CT scanner (MSCT; Brilliance 64, Philips Medical System, Best, the Netherlands) using the following parameters: tube voltage = 120 kV, effective mAs = 350, slice thickness = 1.00 mm, the field of view (FOV) = 180 mm, and image matrix = 768 × 768. The evaluation was performed on the coronal, axial, and sagittal planes in the workstation by a single radiologist.
Measurements
1. Measurement of NLC diameters: The transverse diameters of the NLC were measured by identifying the sections where the canal is the widest, both proximally and distally on both sides (Figure 1).
2. Measurement of MS diameters: The widest section of the MS was identified on PNS CT images, and the maximum anteroposterior and mediolateral dimensions were measured (Figure 2). The height of the MS was assessed from the sections in the coronal plane (Figure 3).
Statistical Analysis
The data collected in the study were analyzed using SPSS for Windows version 20.0 software (SPSS, INC, an IBM Company, Chicago, Illinois). The paired t-test, independent sample t-test, and Pearson correlation test were used. A p-value of less than 0.005 was considered to indicate statistical significance.
Ethical Approval
Ethics committee approval was obtained from the Kirikkale University Non-invasive Research Ethics Committee (Date: 2019-08-07, No: 2019/12).
Results
Nasolacrimal Canal Proximal and Distal Measurements
No significant differences were found between ipsilateral and contralateral NLC proximal; and distal diameters (p>0.05) (Table 1). In each of the ipsilateral, and contralateral groups separately, proximal NLC diameters were significantly higher than that of the distal NLC diameters (p<0.001) (Table 1).
Maxillary Sinus Measurements
No significant differences were found between ipsilateral and contralateral MS measurement values (horizontal, anterior-
posterior dimensions and length) (p>0.05) (Table 1).
The NLC and MS measurements by gender are presented in Table 2.
Nasolacrimal Canal Proximal and Distal Measurements
İpsilateral and contralateral NLC proximal and distal diameters were significantly higher in males compared to females (p<0.05) (Table 2). In both males and females, the ipsilateral proximal NLC diameters were significantly higher than the distal NLC (p<0.05) (Table 2). In females only, contralateral proximal NLC diameters were significantly higher than the distal NLC (p<0.05) (Table 2).
Maxillary Sinus Measurements
In females, the anterior-posterior dimension and height of the ipsilateral MS were significantly lower than those in the males (p<0.05) (Table 2). No significant differences were detected in the contralateral MS measurements (horizontal, anterior-posterior dimensions, and height) between male and female patients (p>0.05) (Table 2).
Nasolacrimal Canal Proximal and Distal Measurements
No significant differences were found between ipsilateral proximal, distal, contralateral proximal, and distal NLC dimensions of the subjects aged ≤25 years and those aged >25 years (p>0.05).
In the ≤25 years age group, contralateral proximal NLC diameters were significantly higher than the distal NLC (p<0.05) (Table 3). In the >25 years age group, both ipsilateral and contralateral proximal NLC diameters were significantly higher than the distal NLC (p<0.05).
Maxillary Sinus Measurements
No significant differences were found in the ipsilateral and contralateral MS measurements (horizontal, anterior-posterior dimensions, and height) between subjects aged 25 years or younger and those older than 25 years (p>0.05).
Correlation test results are presented in Table 3:
-A positive correlation was identified between the ipsilateral proximal NLC diameters and ipsilateral MS heights (p=0.038) (Table 3)
-A positive correlation was found between the ipsilateral proximal NLC diameters and contralateral MS heights. (p=0.040) (Table 3)
-A strong positive correlation exists among all NLC diameter measurements (p<0.05) (Table 3)
-A strong positive correlation was observed among all MS diameter measurements (p<0.05) (Table 3).
-No significant correlation was detected between age and any of the measurement parameters (p>0.05) (Table 3).
Discussion
The ipsilateral and contralateral NLC were evaluated independently. The ipsilateral proximal NLC diameters of the males (4.31±0.83 mm) were significantly wider than females (3.73±0.76 mm), and distal NLC diameters of the males (4.12±0.85 mm) were significantly wider than females (3.47±0.86 mm). Upon examining the contralateral side, the proximal diameter of NLC was 4.27±0.85 mm in men and 3.78±0.66 mm in women (p=0.002). When we examined the contralateral distal part, it was observed as 4.14±0.98 mm in males and 3.49±0.83 mm in females (p=0.001). These findings, consistent with the studies of Sirik et al. [7] and Alfred et al. [8], indicate that the nasolacrimal duct is wider in males than in females, both proximally and distally, and that this difference is not influenced by septum deviation. This could account for the higher prevalence of acquired nasolacrimal duct obstruction in women [9, 10].
MS development is proportional to facial bone development [11, 12]. In our study, the positive correlation between the proximal diameter of the ipsilateral nasolacrimal duct and the height of MS supports this information.
In the study of Whyte et al [13], it was stated that the volume of fully developed MS is higher in men than in women. In our study, the anteroposterior and horizontal diameters of MS on the ipsilateral side were higher in men than in women(p<0.05). However, there is no difference in heights of MS between men and women (p>0.05).
In our study, septum deviation and MS diameters were assessed. It was found that there were no statistically significant differences between ipsilateral and contralateral side diameters(p>0.05). Although we believe that the dimensions of the MS are not affected by the deviation of the septum, it will be beneficial to conduct prospective studies examining whether the deviation occurs during development or in adulthood.
In the study of Cervelli et al. [14] involving adult patients, it was reported that nasolacrimal canal obstruction is more affected by turbinate hypertrophy than by septum deviation [14]. Our findings, which show that NLC diameter measurements were unaffected by septum deviation, support this conclusion. Additionally, many publications in the literature that NLC obstruction frequently occurs at the distal, internal ostium level. In our study, it was observed that the proximal part of the NLC was wider than the distal part on both the ipsilateral and contralateral sides, and this difference was statistically significant (p<0.05). The higher frequency of NLC obstruction in the distal region may be attributed to the narrower canal in that area.
In the study of Dikici et al. [15], 37 patients with primary acquired nasolacrimal canal obstruction (PANCO) in 48 eyes were included, along with 37 patients in the control group. A positive correlation was found between right and left, proximal and distal diameters. There was no significant difference between the groups when the diameter lengths were compared. There was no significant difference between the groups according to the direction and location of the deviation and Mladina classification (p>0.05) [15]. Similar to the findings of Dikici et al. [15], our study also identified a positive correlation between the ipsilateral and contralateral diameters, both proximally and distally. However, no significant difference was observed between the ipsilateral and contralateral groups.
In the studies of Janssen [16], Groel [17], and Lee [18], it was concluded that having a small nasolacrimal canal diameter is one of the etiological factors causing nasolacrimal canal obstruction. In our results, the diameter of the proximal part of the canal was larger than the diameter of the distal part in all groups. Therefore, it can be inferred that the pathologies in the distal part of the canal are more likely to cause obstruction. The fact that lower turbinate hypertrophy causes more obstruction in the studies of Habesoglu [19], Cervelli [14], and Dikici [15] supports this.
In the study of Habeşoğlu et al. [20] involving 41 patients with PANCO, osteomeatal complex disease was observed on the occluded side in 19.5% of the patients and on the healthy side in 5% of the patients. Maxillary sinusitis was observed on the occluded side in 24.4% of the cases, while it was observed on the healthy side in 7.3% of the cases (p<0.05) [20]. Based on the study of Habeşoğlu et al. [20], it can be suggested that there is a relationship between the NLC and MS physiology. In our study, a positive correlation was found between the proximal diameter of the ipsilateral NLC and the height of both the ipsilateral and contralateral MS (p<0.05). Additional research is required to elucidate the developmental connection between the nasolacrimal canal and the maxillary sinus. In the study of Habeşoğlu et al. [20] found no statistically significant association between septum deviation and nasolacrimal duct obstruction in their study [20].
Sirik et al. [7] examined the NLC diameters between the groups with and without deviation, no statistically significant difference was detected [7]. Although the proximal and distal parts were not assessed separately in this study, our analysis showed no statistically significant differences when these parts were evaluated separately. This suggests that there is no relationship between septum deviation and nasolacrimal canal diameter. However, our study did not consider the timing of septal deviation during the developmental process and its potential relationship with NLC diameter.
In Wang et al.’s study [20], PNS CT images of 126 patients with PANCO and a control group consisting of 76 people were examined. The narrowest diameter of the NLC was significantly smaller in the PANCO patient group (p<0.01). The angle between the inferior turbinate and the medial wall of the MS was significantly narrower in the PANCO patient group than in the control group. Given that the distal part of the nasolacrimal canal is narrower, it supports our perspective that pathologies in this region have a greater impact.
Wang et al. [20] found no significant difference in the rate of septal deviation and the side of occlusion between PANCO and the control group, similar to our findings. This supports our view that nasal septal deviation does not affect the diameter of the NLC or the development of PANCO.
In the measurements taken, a positive correlation was found between the proximal diameter of the NLC and bilateral MS heights on the side of the deviation(p<0,005). This suggests that in cases where MS is higher, the proximal diameter of the nasolacrimal duct might be wider, as observed in coronal PNS CT or Waaters X-ray. Particularly in individuals with MS atrophy, there might be issues with the nasolacrimal duct on the same side. Future studies are crucial to further explore and clarify this relationship.
Conclusion
In conclusion, the NLC is wider in men than in women, and it is also wider proximally than distally. This may explain why PANCO is more common in women and why obstruction is frequently observed in the distal part of the canal. The role of septum deviation as an etiological factor in PANCO remains a controversial issue in the medical community, and future studies are important to clarify this issue.
Scientific Responsibility Statement
The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.
Animal and Human Rights Statement
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.
Funding: None
Conflict of Interest
The authors declare that there is no conflict of interest.
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Furkan Melih Kocak, Nuray Bayar Muluk, Mikail Inal, Selcuk Baser, Ziya Şencan Ela Comert, Gökçe Ozel. Evaluation of the Nasolacrimal Canal by Computed Tomography in Patients with Septal Deviation. Ann Clin Anal Med 2024;15(Suppl 2):S127-132
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The integration of artificial intelligence in thoracic surgery: A revolutionary approach
Mesut Buz
Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22267 Received: 2024-05-18 Accepted: 2024-07-29 Published Online: 2024-08-14 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S133
Corresponding Author: Mesut Buz, Department of Thoracic Surgery, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey. E-mail: mesutbuzmd@gmail.com P: +90 530 402 21 66 Corresponding Author ORCID ID: https://orcid.org/0000-0003-1899-8983
To the editor
The rapid pace of technological advancements in thoracic surgery has enhanced the way we treat patients and care for them. One of the most exciting developments is the integration of artificial intelligence (AI) into certain surgeries, which is opening up new possibilities for thoracic surgery. I’d like to highlight a few key points about the role AI is playing in our surgical practices.
First and foremost, AI’s exceptional ability to analyze images is a game-changer, especially when it comes to reading radiology scans. By leveraging AI algorithms to examine high-resolution imaging like CT and MRI scans, we can identify tumors and other abnormalities much earlier and with greater precision. In fact, a recent study showed that AI is just as good as – if not better than – human radiologists when it comes to detecting and classifying lung nodules [1].
Another significant advantage of AI in thoracic surgery is its ability to help create personalized treatment plans for each patient. By combining patient data, genetic information, and clinical records, AI-powered analytics can identify individual risk factors and pinpoint the most effective treatment approaches. For instance, AI-based risk assessment models can predict potential complications after surgery, giving surgeons valuable insights to inform their decision-making [2].
Furthermore, AI is revolutionizing robotic-assisted surgery by enhancing the precision and capabilities of surgeons. By minimizing invasiveness and reducing recovery times, robotic-assisted procedures can significantly reduce postoperative pain and complications. AI can fine-tune the movements of surgical robots and provide real-time feedback to surgeons, making operations safer and more effective [3]. Lastly, AI is also playing a vital role in education and training. When integrated with virtual and augmented reality, AI enables simulations for surgical training, allowing young surgeons to hone their skills and practice complex techniques in a safe and controlled environment. These technologies are crucial in developing surgical expertise and minimizing operational errors [4].
In conclusion, the integration of artificial intelligence in thoracic surgery is nothing short of revolutionary, transforming both diagnosis and treatment. The integration of AI into surgical practice holds the potential to improve patient care and optimize surgical outcomes. Therefore, further research and clinical application of AI technologies could set the standard for future thoracic surgery.
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A terrible short bowel story with a happy ending
Fatma Hilal Yılmaz 1, Musa Silahlı 1, İshak Akıllıoğlu 2
1 Department of Neonatology, 2 Department of Pediatric Surgery, Dr. Ali Kemal Belviranlı Obstetrics and Child Hospital, Konya, Turkey
DOI: 10.4328/ACAM.22270 Received: 2024-05-20 Accepted: 2024-07-29 Published Online: 2024-09-11 Printed: 2024-10-20 Ann Clin Anal Med 2024;15(Suppl 2):S134
Corresponding Author: Fatma Hilal Yılmaz, Department of Neonatology, Dr. Ali Kemal Belviranlı Obstetrics and Child Hospital, Konya, Turkey. E-mail: f.h.yilmaz@hotmail.com P: +90 505 928 23 45 Corresponding Author ORCID ID: https://orcid.org/0000-0002-1152-9773
Other Authors ORCID ID: Musa Silahlı, https://orcid.org/0000-0003-0944-7178 . İshak Akıllıoğlu, https://orcid.org/0000-0002-3226-492X
To the editor
A premature male infant, born at 32 weeks of gestation to an 18-year-old mother via normal spontaneous vaginal delivery, was admitted to the neonatal intensive care unit for respiratory distress with a birth weight of 1860 grams (68th percentile). He was intubated for 5 days and supported with continuous positive airway pressure (CPAP) for 1 day. Ampicillin (2x 100mg/kg) and gentamicin (1x 4.5 mg/kg) were started due to congenital pneumonia. During this period, the patient was fed with an orogastric tube and then switched to oral nutrition. On the postnatal day 14, nutritional intolerance and abdominal tension were observed. The child was consulted for surgery. He underwent surgery for necrotizing enterocolitis. During the first operation, widespread ischemia was observed as skip lesions from the distal terminal ileum to the proximal cecum (Figure 1). The surgical site was closed by placing a drain for a second look. Five days later, the Treitz ligament was preserved, and an ileostomy was performed, leaving a total of 45 cm of ileum in reserve. Postoperatively, by the end of the first day , the ileostomy was functioning, but the patient did not tolerate postoperative nutrition for 58 days. During this time, he received parenteral nutrition (PN). Prolonged PN-induced direct bilirubinemia (9 mg/dL) developed. The amount of lipids in PN was reduced to 1 g/kg/day, and lipids containing medium-chain fatty acids were used. ADEK vitamins were started at the appropriate dose, ursodeoxycholic acid was administered (2×10 mg/kg). During follow-up, direct bilirubinemia decreased and returned to normal. On postoperative day 48, the ileostomy was closed. On postoperative day 58, he began to tolerate enteral nutrition. After that, he experienced periods when he could not tolerate enteral nutrition, so TPN could not be discontinued. On postnatal day 146, he tolerated full enteral nutrition (breast milk and fully hydrolyzed formula), and PN was stopped. The patient, whose daily weight gain increased up to 30 grams, whose defecation was of normal consistency, and who was fed orally, was referred to the intestinal center for gastroenterology and pediatric surgical follow-up and was discharged. The discharge weight was 3145 grams (<3rd percentile).
The malabsorptive condition known as short bowel syndrome (SBS) can develop as a result of major small intestine surgical resection, disease-related loss of absorption, or congenital surgical malformations [1]. Nearly one-third of all recorded cases are caused by necrotizing enterocolitis [2]. In some publications, this rate can be as high as 49% [3]. Sepsis, cholestasis, intestinal failure, and even death are possible outcomes of short bowel syndrome. The use of PN has enhanced SBS medical care, lowering mortality and improving overall prognosis. However, chronic PN usage is linked to a higher risk of several side effects, such as bloodstream infections, catheter-associated problems, and liver disease [3]. Carefully monitoring nutritional status, avoiding PN and favoring an early introduction of enteral nutrition, as well as preventing, diagnosing, and aggressively treating catheter-associated bloodstream infections and small intestine bacterial overgrowth can all result in a significant improvement in prognosis [4]. A multidisciplinary strategy is used in the treatment of patients with SBS. This approach starts in the neonatal critical care unit and includes nurses, pediatric surgeons, dietitians, pharmacists, and neonatologists. Later on, children transition to an intestinal rehabilitation program.
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3. Mutanen A, Lilja HE, Wester T, Norrby H, Borg H, Persson S et al. A nordic multicenter study on contemporary outcomes of pediatric short bowel syndrome in 208 patients. Clin Nutr. 2023;42(7):1095-103.
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