Supplement 3 2025
Outcomes of volar locking plate fixation in unstable distal radius fractures
Humam Baki 1, Yusuf Öztürkmen 2
1 Department of Orthopedics, Private Gaziosmanpaşa Hospital, 2 Department of Orthopedics, Health Sciences University, Istanbul Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22784 Received: 2025-06-22 Accepted: 2025-07-28 Published Online: 2025-08-09 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S137-141
Corresponding Author: Humam Baki, Department of Orthopedics, Private Gaziosmanpaşa Hospital, Istanbul, Turkey. E-mail: humambakimd@gmail.com P: +90 212 444 13 00 Corresponding Author ORCID ID: https://orcid.org/0009-0006-8924-220X
Other Authors ORCID ID: Yusuf Öztürkmen, https://orcid.org/0000-0002-2199-2411
This study was approved by the Ethics Committee of Health Sciences University, İstanbul Training and Research Hospital (Date: 2016-12-09, No: 892)
Aim: Unstable distal radius fractures often necessitate surgical fixation to restore anatomy and preserve wrist function. This study aimed to evaluate the functional and radiological outcomes of volar locking plate fixation in adult patients with unstable distal radius fractures.
Materials and Methods: This retrospective single-center study was conducted at a tertiary care hospital in Türkiye over a 3.5-year period. Unstable distal radius fractures were identified based on Lafontaine’s radiographic criteria. All patients were treated using a volar locking plate via the Henry approach. Postoperatively, a standardized early mobilization protocol was implemented, with splint removal and initiation of wrist exercises on postoperative day 15. Functional outcomes were assessed using the Modified Mayo Wrist Score and the Turkish version of the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH-T) questionnaire, while radiological outcomes were evaluated using the Stewart radiological scoring system.
Results: A total of 51 unstable distal radius fractures were treated with volar locking plates. At final follow-up, 56.9% of patients had excellent and 21.6% had good functional outcomes, as assessed by the Modified Mayo Wrist Score. The mean Quick DASH-T score was 19.9 ± 20.4. Radiographic parameters, including radial height, inclination, and palmar tilt, showed marked improvement postoperatively. The Stewart score indicated excellent or good results in 98% of cases. The overall complication rate was 10%.
Discussion: Volar locking plate fixation provides reliable anatomical restoration and favorable functional outcomes in patients with unstable distal radius fractures, with a low complication rate.
Keywords: distal radius fracture, volar locking plate, internal fixation, functional outcome, radiographic assessment
Introduction
The wrist joint is a highly complex and mobile structure that plays a central role in functional hand activities. Its anatomical vulnerability contributes to a high incidence of trauma, with distal radius fractures (DRFs) being the most commonly encountered fractures of the upper limb, comprising nearly 15% of all skeletal injuries presenting to emergency departments [1]. While many DRFs are stable and amenable to conservative treatment, unstable fractures—particularly those that are intra-articular, comminuted, or associated with dorsal angulation—often require surgical fixation to restore anatomy and prevent long-term dysfunction [2]. Over the past two decades, open reduction and internal fixation (ORIF) with volar locking plates (VLPs) has become the preferred surgical technique due to its ability to provide angular stability and facilitate early mobilization [3].
Biomechanical advantages of VLPs, such as subchondral buttressing and fixed-angle screw-plate constructs, are particularly beneficial in osteoporotic bone [4]. Moreover, the volar approach significantly reduces the risk of extensor tendon irritation, which is commonly seen with dorsal plating [5]. Several prospective and retrospective studies have demonstrated excellent functional and radiographic outcomes with VLPs, including consistent restoration of volar tilt, radial height, and radial inclination [6,7]. Functional recovery, often assessed via the DASH and Mayo wrist scores, has been shown to be superior or equivalent to external fixation, with lower complication rates [8].
However, controversy persists regarding the ideal implant design, screw configuration, and optimal approach for specific fracture types [9]. This study aims to retrospectively evaluate the clinical and radiological outcomes of patients treated with VLP for unstable distal radius fractures, focusing on anatomical restoration and functional recovery.
Material and Methods
Study Design
This retrospective study was conducted at the Orthopedics and Traumatology Department of İstanbul Training and Research Hospital. Medical records of patients who presented to the emergency department between March 2010 and September 2013 and were diagnosed with unstable distal radius fractures were reviewed. Eligibility for surgical treatment was determined based on radiographic instability [10].
Radiographic Assessment and Classification
All patients underwent standard anteroposterior and lateral wrist radiographs at initial presentation. When necessary, computed tomography (CT) was used to further assess fracture morphology, particularly for evaluating intra-articular extension and comminution, which are critical in preoperative planning [11]. Fractures were classified using both the Frykman and AO classification systems, independently by two orthopedic surgeons.
Fracture instability was defined according to the La Fontaine criteria, which include:
• Dorsal angulation >20°
• Comminution of the dorsal cortex
• Intra-articular extension
• Associated ulnar fracture
• Age over 60 years
These criteria have been shown to strongly predict secondary displacement in conservatively treated fractures [12,13]. Patients with at least one of these features were considered to have unstable fractures and were included in the study.
Surgical Technique
All surgical procedures were performed under tourniquet control with the patient in the supine position. After appropriate anesthesia (general or regional), a volar longitudinal incision was made along the flexor carpi radialis tendon. Fracture fragments were anatomically reduced, and temporary fixation was achieved with K-wires when necessary. Definitive fixation was performed using fixed-angle volar locking plates. The accuracy of reduction and implant placement was verified fluoroscopically. The pronator quadratus muscle was repaired over the plate in all cases, as standard in volar plating techniques to minimize tendon irritation [6]. All fractures were fixed using the same model of fixed-angle titanium volar locking plate.
Postoperative Management and Follow-Up
A short-arm splint in the neutral position was applied postoperatively. Patients began finger range-of-motion exercises and forearm pronation-supination movements on postoperative day 1. Wrist mobilization was initiated following suture removal on postoperative day 15, in line with early rehabilitation protocols to improve outcomes [4]. Clinical and radiological evaluations were performed at regular intervals until fracture healing and functional recovery.
Outcome Measures
Functional outcomes were assessed using the Modified Mayo Wrist Score and the Turkish version of the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH-T) score, both validated tools for upper limb function [14,15]. Radiographic outcomes were evaluated using the Stewart radiological criteria, which include assessment of radial height, inclination, and volar tilt [7].
Statistical Analysis
Statistical analyses were performed using SPSS version 16.0. Descriptive statistics were used to summarize patient characteristics. The Kruskal–Wallis test was applied to compare functional and radiological scores across three predefined age groups (28–44 years, 45–60 years, and over 60 years). A p-value <0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Health Sciences University, İstanbul Training and Research Hospital (Date: 2016-12-09, No: 892). Due to the retrospective nature of the study, the requirement for informed consent was waived by the committee.
Results
A total of 50 patients (28 males [56%] and 22 females [44%]) with 51 unstable distal radius fractures were included. The mean age was 50.2 years (range, 28–79). Patients were categorized into three age groups: 28–44 years (n=20, 40%), 45–60 years (n=19, 38%), and over 60 years (n=11, 22%). The most common mechanism of injury was a simple fall (70%), followed by high-energy trauma such as falls from height (12%), motor vehicle accidents (12%), assault (4%), and bicycle accidents (2%). At final follow-up, both clinical and radiological outcomes were evaluated. According to the Modified Mayo Wrist Score, 29 cases (56.9%) were classified as excellent, 11 (21.6%) as good, 10 (19.6%) as fair, and 1 (1.9%) as poor. The mean Quick DASH-T score was 19.9 ± 20.4 (range, 0–74) (Table 1). Radiographic evaluation revealed marked improvement following surgical intervention. Mean radial height increased from 4 mm preoperatively to 15 mm postoperatively; radial inclination improved from 7° to 22°; and palmar tilt from –9° to 3°. According to Stewart’s radiological scoring system, 38 cases (74.5%) had excellent results, 12 (23.5%) were good, and 1 (2.0%) was fair (Table 2). Joint congruency was restored in all but two cases. At final follow-up, mean wrist dorsiflexion was 70° (range 55–85°), palmar flexion 75° (60–90°), ulnar deviation 35° (25–45°), and radial deviation 25° (15–35°). Mean pronation and supination were 80° (75–85°) and 85° (75–95°), respectively. The average time to return to work or daily activities was 56 days (range 30–150) (Table 3). No intraoperative complications such as vascular injury or tendon rupture were observed. During follow-up, carpal tunnel syndrome occurred in 2 patients, surgical site pain in 1, and flexor tenosynovitis in 1 patient. No cases of Sudeck’s atrophy or arthritis were detected (Table 3). Subgroup analysis based on age groups revealed a clear trend in functional outcomes. The mean Modified Mayo Score was highest in the 28–44 age group (31.3), followed by the 45–60 group (24.1), and lowest in patients aged over 60 years (19.1), as illustrated in Figure 1. This gradient suggests age as a potential determinant of postoperative recovery, likely reflecting both bone quality and rehabilitation potential. Radiographic parameters also demonstrated marked improvement following volar plate fixation. Radial height increased from 4 mm to 15 mm, radial inclination from 7° to 22°, and palmar tilt from –9° to 3°, supporting the anatomical restoration achieved with volar plating (Figure 2). An illustrative case example is presented in Figure 3, demonstrating the radiological improvement achieved postoperatively.
Discussion
In this study, we retrospectively evaluated 51 distal radius fractures in 50 patients who underwent volar locked plating due to instability criteria. According to the Modified Mayo Wrist Score, 56.9% of fractures had excellent outcomes, 21.6% good, 19.6% fair, and only 1.9% poor—findings that are consistent with prior reports showing favorable functional results after volar plate fixation [16]. The mean Quick DASH-T score was 19.9 ± 20.4, in line with other studies reporting mean scores between 14 and 20 after 1 year [17]. The Stewart radiological scoring system demonstrated excellent outcomes in 74.5% of cases, similar to other prospective studies showing radiographic success rates above 70% [18]. Restoration of key radiological parameters—radial height, inclination, and palmar tilt—was achieved postoperatively [19]. Complication rates remained low, with no major tendon injuries and only one patient requiring plate removal due to pain, confirming findings of minimal complications with volar plating [20].
The management of unstable distal radius fractures remains an evolving topic. Although conservative treatment remains effective for stable extra-articular fractures, it is often insufficient in achieving long-term anatomical and functional restoration in displaced, intra-articular, or osteoporotic fractures [16]. Our patient selection was based on widely accepted instability criteria, including those by Lafontaine et al. [10], ensuring homogeneity of the cohort with true instability risk. Notably, our patients had a mean age of 50.2 years, and although over 70% of fractures resulted from simple falls, they still met criteria for instability, echoing findings by Mackenney et al. that patient age and fracture morphology are better predictors of instability than trauma mechanism alone [13].
Several radiological parameters have been associated with long-term function. Restoration of radial height and palmar tilt has been linked to improved wrist biomechanics [21]. Our postoperative values (radial height: 15 mm, inclination: 22°, tilt: 3°) and range of motion outcomes (dorsiflexion: 70°, palmar flexion: 75°, pronation-supination: near-full) align with the literature, confirming volar plating’s capability to restore both anatomy and function [18,19].
The debate between dorsal and volar plating persists. Dorsal approaches carry higher risks of extensor tendon irritation and rupture, whereas volar plating, particularly when kept proximal to the watershed line, offers a biomechanically favorable and safer alternative [16,17]. In our cohort, even complex intra-articular AO type C fractures were successfully managed with volar plating alone, consistent with clinical recommendations favoring volar-only fixation for many complex patterns [16].
The overall complication rate in our study was 10%, which is favorable compared to rates up to 30% in other series [17]. Importantly, there were no extensor tendon injuries, stressing the protective benefit of the volar approach. Younger patients in our cohort achieved significantly higher functional scores, reflecting better healing potential and rehabilitation compliance, consistent with previous literature [16]. However, patients over 60 also experienced satisfactory outcomes, affirming the efficacy of stable internal fixation and early mobilization across age groups [18].
Limitations
This study has several limitations that should be acknowledged. First, its retrospective design inherently limits causal inference and is prone to selection and information bias. Second, the absence of a control group—such as patients treated conservatively or with alternative surgical techniques—precludes direct comparisons regarding the relative efficacy of volar plating. Third, the radiological evaluation was based solely on plain radiographs; advanced imaging modalities such as CT were not routinely used, potentially underestimating articular incongruities or subtle malreductions. Additionally, the functional outcomes were assessed at varying follow-up durations, which may introduce variability in the scores. Lastly, although clinical and radiological data were systematically collected, patient-reported outcome measures beyond Quick DASH-T were not utilized, limiting a more comprehensive assessment of subjective satisfaction and quality of life. Future prospective, controlled studies with standardized imaging and functional follow-up are warranted to validate and extend these findings.
Conclusion
Volar locked plating using the Henry approach was associated with reliable fracture stabilization, early mobilization, and favorable clinical and radiological outcomes in adults with unstable distal radius fractures. The low complication rate supports its continued use as a first-line surgical strategy in selected patients. Future prospective studies comparing implant designs and long-term functional recovery across age groups may further optimize treatment algorithms.
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, and 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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Humam Baki, Yusuf Öztürkmen. Outcomes of volar locking plate fixation in unstable distal radius fractures. Ann Clin Anal Med 2025;16(Suppl 3):S137-141
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Radiation dose and duration in coronary angiography: Driving inflammation in acute coronary syndrome patients?
Murat Ozmen 1, İsa Ardahanli 2
1 Department of Cardiology, School of Medicine, University of Health Sciences, Erzurum Bolge Training and Research Hospital, Erzurum, Turkey, 2 Department of Cardiology, School of Medicine, Bilecik Seyh Edebali University, Bilecik, Turkey
DOI: 10.4328/ACAM.22865 Received: 2025-08-27 Accepted: 2025-09-29 Published Online: 2025-10-22 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S142-147
Corresponding Author: Murat Özmen, Department of Cardiology, School of Medicine, University of Health Sciences, Erzurum Bolge Training and Research Hospital, Erzurum, Turkey. E-mail: drmuratt1987@gmail.com P: +90 554 176 72 20 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6237-1398
Other Authors ORCID ID: İsa Ardahanli, https://orcid.org/0000-0002-9309-803X
This study was approved by the Ethics Committee of Erzurum City Hospital (Date: 2022-07-04, No: 2022/09-122)
Aim: Coronary angiography, a vital diagnostic and therapeutic procedure for patients with acute coronary syndrome (ACS), involves radiation exposure. This radiation exposure has the potential to trigger an inflammatory response, which may negatively impact clinical outcomes. This study investigated the relationship between radiation exposure, as measured by cumulative air kerma (CAK) and duration, and inflammatory markers during coronary angiography.
Materials and Methods: This retrospective study included 230 patients who underwent coronary angiography for suspected ACS. Demographic characteristics, medical history, and angiographic findings were recorded. C-reactive protein (CRP) and white blood cell (WBC) levels were measured before and after the procedure. Radiation exposure was recorded as CAK and duration using the fluoroscopy system.
Results: The mean age of the patients was 63.82 ± 12.64 years, and 70.6% were male. A statistically significant positive correlation was found between radiation dose (CAK) and duration, and post-procedure CRP and WBC levels (p<0.05). For instance, patients with higher CAK values had significantly increased post-procedure CRP and WBC levels.
Discussion: Radiation exposure during coronary angiography can trigger an inflammatory response, potentially leading to prolonged hospital stays and an increased risk of infection. Therefore, it is crucial to minimize radiation exposure, particularly in high-risk patients (e.g., elderly, diabetic). This can be achieved through careful pre-procedural planning, implementation of radiation reduction protocols, and the use of experienced operators. Future studies should investigate protective strategies to mitigate the impact of radiation on the inflammatory response.
Keywords: coronary artery angiography, radiation exposure, systemic inflammation, acute coronary syndrome, C-reactive Protein, white blood cells
Introduction
Acute coronary syndrome (ACS), a constellation of clinical presentations including ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris, represents a spectrum of acute myocardial ischemia resulting from a sudden reduction in coronary blood flow [1]. This abrupt cessation of adequate perfusion to the myocardium triggers a cascade of pathophysiological events, culminating in myocardial necrosis and potentially life-threatening complications [2]. Despite advances in medical management and interventional cardiology, ACS remains a leading cause of morbidity and mortality worldwide, underscoring the urgent need for continued research into its underlying mechanisms and innovative therapeutic approaches [3].
The etiopathogenesis of ACS is complex and multifaceted, involving an intricate interplay of traditional risk factors such as hyperlipidemia, hypertension, diabetes mellitus, and smoking, in conjunction with emerging contributors such as inflammation and endothelial dysfunction [4]. While the occlusion of a coronary artery by atherosclerotic plaque rupture or erosion is the hallmark of ACS, recent investigations have elucidated the pivotal role of inflammation in all stages of atherosclerotic plaque development, from its initiation to its eventual destabilization and rupture [5].
Inflammatory cells, including macrophages and lymphocytes, infiltrate the arterial wall, releasing many cytokines, chemokines, and reactive oxygen species that perpetuate a chronic inflammatory state [6]. This inflammatory milieu promotes endothelial dysfunction, lipid oxidation, and smooth muscle cell proliferation, ultimately contributing to plaque growth and vulnerability. Furthermore, inflammatory mediators can trigger platelet activation and the coagulation cascade, leading to thrombus formation and acute coronary occlusion [7].
C-reactive protein (CRP), an acute-phase reactant synthesized by the liver in response to inflammation, has emerged as a sensitive biomarker of systemic inflammation and cardiovascular risk. Elevated CRP levels have been associated with increased risk of ACS, adverse cardiac events, and mortality in various patient populations. Moreover, CRP may play a direct role in atherogenesis by promoting endothelial dysfunction, monocyte adhesion, and foam cell formation [8,9].
Coronary angiography, an invasive imaging modality that visualizes the coronary arteries, is indispensable in diagnosing and managing ACS. It enables identifying culprit lesions, assessing coronary anatomy, and guiding percutaneous coronary interventions [10]. However, this procedure entails exposure to ionizing radiation, which can induce DNA damage, oxidative stress, and cellular injury. The cumulative air kerma (CAK), measured in milligrays (mGy), quantifies the radiation dose delivered to the patient during fluoroscopy and is a critical parameter in assessing radiation risk [11,12].
Several studies have suggested a potential association between radiation exposure during coronary angiography and adverse outcomes, including increased risk of restenosis, myocardial infarction, and mortality [13,14]. The underlying mechanisms involve radiation-induced inflammation and oxidative stress, which may promote atherogenesis, thrombosis, and vascular remodeling [15,16]. However, the precise relationship between radiation dose and inflammatory response in ACS patients must still be better understood.
This study investigates the relationship between radiation dose and duration measured by CAK and inflammatory markers (especially CRP and WBC count) in coronary angiography patients due to ACS. A better understanding of this relationship may help to evaluate the possible effect of radiation exposure on the inflammatory response in this patient group. The findings may contribute to strategies to minimize radiation exposure and reduce possible side effects, thus improving ACS patients’ treatment and care processes.
Materials and Methods
Study Design and Population
This retrospective observational study was conducted at the Erzurum City Hospital Cardiology Clinic. The study population consisted of 230 adult patients (age > 18 years) who underwent coronary angiography for suspected acute coronary syndrome (ACS) between January 1, 2022, and April 1, 2022. Data from these patients were accessed after ethics committee approval on July 10, 2022. No information that could identify individual participants was accessed during or after data collection. The diagnosis of ACS was established based on clinical presentation, electrocardiographic findings, and cardiac biomarker levels, specifically including patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). ACS was diagnosed according to the criteria set out in the 2023 ESC Guidelines for managing acute coronary syndromes of the European Society of Cardiology (ESC). The primary endpoint of this study was to evaluate the correlation between radiation dose and duration and inflammatory markers.
Inclusion and Exclusion Criteria
Patients were included in the study if they met the following criteria: (Figure 1).
Age Over 18 Years
Diagnosis of ACS (STEMI or NSTEMI)
Availability of complete pre- and post-procedure laboratory data in the hospital’s electronic medical record system, including:
o Hemogram (leukocyte count, platelet count)
o Biochemistry panel
o C-reactive protein (CRP) levels
Patients Were Excluded From the Study If They Had:
A History of Malignancy
Incomplete or Missing Laboratory Data
Prior radiation exposure: Any significant radiation exposure within the past 6 months, including radiotherapy, nuclear medicine scans, or repeated diagnostic imaging procedures, to avoid confounding effects on inflammatory markers.
Active Infection or Inflammatory Conditions
Chronic inflammatory diseases: Pre-existing chronic inflammatory diseases, such as rheumatoid arthritis, inflammatory bowel disease, or systemic lupus erythematosus, could influence baseline and post-procedure inflammatory marker levels.
Use of Anti-inflammatory Medications
Hematological disorders: Any hematological disorders affecting leukocyte counts, such as leukemia, lymphoma, or myeloproliferative neoplasms.
Renal or hepatic impairment: Significant renal or hepatic impairment, as these conditions can affect CRP levels and other inflammatory markers.
Pregnancy or Lactation
Data Collection
Demographic data, medical history, and angiographic findings were extracted from the electronic medical records. Laboratory data, including CRP and leukocyte levels, were collected at two time points:
Pre-procedure: At the time of admission to the catheterization laboratory
Post-procedure: In the coronary intensive care unit after the procedure
Radiation exposure data were obtained from the Siemens Artis Q fluoroscopy device used for coronary angiography. The following parameters were recorded for each patient:
Cumulative air kerma (CAK), measured in milligrays (mGy), Procedure duration
Statistical Analysis
Categorical variables were summarized using frequencies and percentages. Continuous variables were assessed for normality using the Kolmogorov-Smirnov test. Normally distributed continuous variables were presented as mean ± standard deviation (SD), while non-normally distributed variables were presented as median (interquartile range [IQR]). The association between radiation exposure (CAK and procedure time) and inflammatory markers (CRP and WBC levels) was evaluated using Spearman’s rank correlation coefficient. All statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 23.0. Statistical significance was defined as a two-sided p-value of <0.05.
Ethical Approval
This study was approved by the Ethics Committee of Erzurum City Hospital (Date: 2022-07-04, No: 2022/09-122).
Results
Study Population
A total of 230 patients were included in this retrospective study (Figure-1). Most patients were male (70.6%), with a mean age of 63.82 ± 12.64 years (range 25-90). The prevalence of comorbidities was as follows: coronary artery disease (48.7%), hypertension (68.7%), and diabetes mellitus (40.9%). The average radiation exposure time during coronary angiography was 17.56 minutes, with an average radiation dose of 1985.04 mGy. Our study detected coronary artery disease in 118 (51.3%) of 230 patients. 58 (49.2%) of these patients underwent revascularization. 45 (77.6%) of the revascularization procedures were PCI, and 13 (22.4%) were CABG. Table 1 provides a comprehensive overview of the descriptive statistics for all variables.
Correlation Between Radiation Exposure And Inflammatory Markers WBC and Radiation Exposure:
A statistically significant, weak positive correlation was observed between radiation duration and WBC taken before the procedure (WBC-1; r=0.174, p=0.008) and WBC taken after the procedure (WBC-2; r=0.219, p=0.001). Similarly, a statistically significant, weak positive correlation was found between radiation dose and pre-procedure WBC-1 (r=0.174, p=0.008) and post-procedure WBC-2 (r=0.202, p=0.003). No significant correlation was observed between radiation exposure (dose or duration) and WBC (WBC-2 – WBC-1) change (Table 2).
A statistically significant weak positive correlation was found between radiation duration and pre-procedure CRP (CRP-1; r=0.153, p=0.027) and post-procedure CRP (CRP-2; r=0.156, p=0.036). No significant correlation was observed between radiation dose and pre-procedure CRP-1 and post-procedure CRP-2 (Table-3).
Correlations with radiation dose and duration for WBC are similar and statistically significant. For CRP, correlations with radiation dose appear stronger than with radiation duration.
Confounders may be affecting these relationships. These include:
• Patient characteristics: Age, gender, general health, comorbidities (especially those affecting the immune system or inflammation), smoking status, genetics, etc.
• Radiation type: Different types of radiation have different biological effects.
• Time since radiation: Inflammatory responses may change over time after exposure.
• Medications: Many medications, including steroids and anti-inflammatory drugs, can affect WBC and CRP levels.
• Infections: Infections can cause significant changes in WBC and CRP.
Graphical Representation
Scatter plots were generated to visualize the relationships between radiation exposure (time and dose) and inflammatory markers (WBC and CRP). Figure 2 shows scatter plots showing positive correlations between radiation duration and dose and pre- and post-procedure WBC levels.
The results of this study indicate a statistically significant, albeit weak, positive correlation between radiation exposure during coronary angiography and subsequent increases in WBC and CRP levels.
Discussion
Our study provides a groundbreaking investigation into the previously unexplored association between radiation exposure during coronary angiography and subsequent inflammatory responses in patients presenting with acute coronary syndrome (ACS). The well-established detrimental effects of radiation on human health have spurred extensive research across various medical disciplines. However, the specific interaction between radiation exposure during coronary angiography and the inflammatory response in ACS patients has mainly remained uncharted.
The significant post-procedural elevation in CRP and WBC values observed in our study aligns with an emerging body of evidence linking radiation exposure to heightened inflammatory states [17,18]. Based on the potential for radiation to trigger systemic inflammatory activation via acute-phase reactants in previous studies, our findings demonstrate a clear and measurable inflammatory response even with the relatively brief radiation exposure associated with coronary angiography [19]. This observation underscores the heightened sensitivity of ACS patients to radiation-induced cellular stress and potential tissue damage.
The concurrent increase in CRP and WBC count paints a picture of a complex immune response to radiation-induced injury. While the precise molecular pathways require further elucidation, releasing damage-associated molecular patterns (DAMPs) from irradiated cells likely plays a central role. These DAMPs act as potent activators of innate immune pathways, leading to the recruitment and activation of leukocytes, thereby fueling the inflammatory cascade [20]. Considering the unique vulnerability of ACS patients in this context is imperative. The pre-existing inflammatory milieu associated with ACS, coupled with the acute physiological stress of the coronary event, may predispose these patients to exaggerated inflammatory responses following radiation exposure. The observed elevation in inflammatory biomarkers post-angiography raises concerns about potential downstream consequences. Persistent inflammation may hinder healing, prolong hospitalization, and increase susceptibility to nosocomial infections [21]. These potential complications warrant further investigation to determine the clinical implications of our findings. While our study did not include albumin assessment, the existing literature suggests a potential decline in this marker following radiation exposure [22]. Albumin, a harmful acute-phase protein, often exhibits an inverse relationship with CRP during inflammatory states [23]. Incorporating albumin measurement into future studies could provide valuable insights into the systemic effects of radiation exposure in ACS patients, potentially revealing a broader impact on protein metabolism and nutritional status.
Our study distinguishes itself from previous research by focusing on patient-specific radiation dose and its direct correlation with inflammatory markers. While prior studies have explored the effects of radiation on cardiac energy metabolism and operator safety, our findings fill a critical knowledge gap by highlighting the direct impact of radiation on the inflammatory response in ACS patients [24,25]. This novel perspective underscores the importance of minimizing radiation exposure whenever feasible, particularly in this high-risk population. This study provides an important investigation into the relationship between radiation exposure during coronary angiography and inflammatory markers. However, some limitations should be considered when interpreting the results and directing future research.
First, the study has a retrospective design, so it is impossible to draw definitive conclusions about causality. Additionally, the study was conducted at a single center, so the generalizability of the findings to other populations may be limited. The sample size was also relatively small, which may affect the study’s statistical power. Finally, the study only evaluated short-term inflammatory responses. More research is needed on the long-term effects of radiation exposure and possible clinical outcomes.
Limitations
Because our study was single-center and the sample size was relatively small, the generalizability of our findings to other populations may be limited. Furthermore, our retrospective design prevents us from drawing definitive conclusions about causality.
Conclusion
Our study highlights the importance of optimizing radiation dose in patients undergoing coronary angiography, especially those with acute coronary syndromes. Minimizing unnecessary radiation exposure can reduce the risk of increased inflammation and related adverse outcomes. This may lead to reduced infection susceptibility, shorter hospital stays, and improved overall outcomes. However, these results should be evaluated within the context of the limitations of our retrospective study and need to be confirmed in prospective studies. Long-term follow-up studies, in particular, would be helpful to better assess the impact of radiation exposure on clinical outcomes. Strategies to reduce radiation dose include strict adherence to evidence-based imaging protocols, avoiding unnecessary repeat or additional projections, and having experienced operators perform the procedure. Streamlining postprocedural care and early initiation of discharge planning may also help reduce hospital stays.
In conclusion, a multifaceted approach focused on reducing radiation dose may improve coronary angiography’s safety and efficacy and improve patient care. However, more research is needed in this area.
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, and 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.
References
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3. Dimitroglou Y, Aggeli C, Theofilis P, et al. Novel anti-inflammatory therapies in coronary artery disease and acute coronary syndromes. Life (Basel). 2023;13(8):1669.
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5. Dendramis G, Paleologo C, Lo Presti A, et al. Ectasia delle arterie coronarie: eziopatogenesi, diagnosi e trattamento [Coronary artery ectasia: etiopathogenesis, diagnosis and treatment]. G Ital Cardiol (Rome). 2014;15(3):161-9.
6. Ma S, Qian H, Zhou Q, Lei C. Hsa_circ_0007765 promotes platelet-derived growth factor-BB-induced proliferation and migration of human aortic vascular smooth muscle cells in Atherosclerosis. Cardiovasc Toxicol. 2024;24(10):1077-89.
7. Shang D, Liu H, Tu Z. Pro-inflammatory cytokines mediating senescence of vascular endothelial cells in atherosclerosis. Fundam Clin Pharmacol. 2023;37(5):928-36.
8. Kuppa A, Tripathi H, Al-Darraji A, Tarhuni WM, Abdel-Latif A. C-reactive protein levels and risk of cardiovascular diseases: A two-sample bidirectional mendelian randomization study. Int J Mol Sci. 2023;24(11):9129.
9. Ardahanlı I, Özmen M. C-Reactive protein to albumin ratio may be an inflammatory indicator for the coronary slow flow phenomenon. Lokman Hekim Health Sci. 2023;3(1):32-7.
10. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(3):e4-e17.
11. Anim-Sampong S, Antwi WK, Adomako JB, Botwe BO, Sarkodie BD, Brakohiapa EK. Patient radiation dose during diagnostic and interventional cardiology procedures: A study in a tertiary hospital. J Med Imaging Radiat Sci. 2023;54(2):298-305.
12. Keenen TL, Demirel S, Gheen A, Casabarro B, Fleishman D. Intraoperative Fluoroscopy Radiation Using OEC 9900 Elite C-arm: Risk and Method for Decreasing Exposure. Health Phys. 2023;124(5):380-90.
13. Stocker TJ, Abdel-Wahab M, Möllmann H, Deseive S, Massberg S, Hausleiter J. Trends and predictors of radiation exposure in percutaneous coronary intervention: the PROTECTION VIII study. EuroIntervention. 2022;18(4):e324-e332.
14. Suwa H, Koyabu Y, Adachi T, et al. Usefulness of dual-axis rotational coronary angiography in primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction. Heart Vessels. 2021;36(5):621-9.
15. Ramadan R, Baatout S, Aerts A, Leybaert L. The role of connexin proteins and their channels in radiation-induced atherosclerosis. Cell Mol Life Sci. 2021;78(7):3087-103.
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Murat Ozmen, İsa Ardahanli. Radiation dose and duration in coronary angiography: Driving inflammation in acute coronary syndrome patients? Ann Clin Anal Med 2025;16(Suppl 3):S142-147
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Impact of preoperative systemic inflammation on clinical recovery following arthroscopic rotator cuff repair
Mahmut Günay
Department of Orthopedics and Traumatology, Faculty of Medicine, Giresun University, Giresun, Turkey
DOI: 10.4328/ACAM.22876 Received: 2025-09-02 Accepted: 2025-10-13 Published Online: 2025-10-23 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S148-151
Corresponding Author: Mahmut Günay, Department of Orthopedics and Traumatology, Faculty of Medicine, Giresun University, Giresun, Turkey. E-mail: drmahmut106@gmail.com P: +90 533 551 85 36 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2746-9349
The study was approved by the Ethics Committee of Giresun University Education and Research Hospital Clinical Research Ethics Committee (Date: 2024-12-11, No: 01)
Aim: This study aimed to investigate the impact of preoperative inflammation values on postoperative recovery in patients who underwent arthroscopic rotator cuff repair.
Materials and Methods: A total of 36 patients who underwent surgery between January 2023 and June 2024 at the Giresun State Hospital Orthopedics and Traumatology Clinic were included. The preoperative inflammation values of the patients were compared with the pre-to-postoperative changes in Oxford Shoulder Score (OSS) and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores.
Results: The mean age of the patients was 64.25 (43-82). Of the patients, 61.1% were female. It was determined that 72.2% of the tears were on the right side, and the most common tear size was moderate (36.1%). Diabetes was observed in 19.4% of the patients. There were significant changes in OSS and Quick DASH scores before and after surgery (p < 0.001). No statistically significant correlation was found between the change in Quick DASH and OSS scores and inflammatory mediators (p > 0.05).
Discussion: We concluded that the preoperative inflammation level did not contribute to clinical and functional recovery after arthroscopic rotator cuff repair.
Keywords: arthroscopic rotator cuff repair, Oxford Shoulder Score, Quick DASH score
Introduction
Rotator cuff tears (RCT) are among the most frequently encountered musculoskeletal pathologies of the shoulder joint [1]. Nowadays, different surgical techniques such as open, mini-open, and arthroscopic methods are used for cases requiring surgical intervention [2]. Arthroscopic rotator cuff repair (RCR) is currently considered the gold standard in the treatment of these tears [3]. However, the level of functional recovery following this surgical procedure can vary considerably among patients. Although clinical outcomes are influenced by numerous factors, the patient’s systemic inflammatory response is also considered an important determinant [4].
In recent years, certain systemic inflammatory markers based on hematological parameters have been reported as prognostic indicators in various surgical procedures [5-6]. These markers are known as Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Lymphocyte-to-Monocyte Ratio (LMR), Systemic Immune-Inflammation Index (SII) [(Neutrophil × Platelet)/Lymphocyte], and Systemic Inflammation Response Index (SIRI) [(Neutrophil × Monocyte)/Lymphocyte]. These markers, reflecting the patient’s preoperative inflammatory status, may be related to postoperative processes such as wound healing, tissue regeneration, and pain levels. Some studies in orthopedic surgery have reported that high NLR and SII levels increase the risk of postoperative complications and prolong the recovery process [7].
The use of clinical measurement tools is of great importance in the objective evaluation of functional recovery. In this context, OSS and Quick DASH scales are widely accepted as reliable and valid tools for assessing upper extremity function [8-9]. These tools are frequently used to monitor changes in functional levels of patients, especially following shoulder surgery.
The aim of this study is to examine the levels of systemic inflammatory markers before surgery in patients undergoing arthroscopic RCR and to evaluate the effects of these markers on OSS and Quick DASH scores measured at the 3rd postoperative month. In this direction, the potential role of hematological inflammatory parameters in predicting postoperative clinical recovery will be investigated.
Materials and Methods
In our clinic (Ilhan Ozdemir State Hospital Orthopedic Clinic), the results of 36 patients who met the inclusion criteria among 55 patients who underwent surgical treatment for full-thickness RCT between January 2023 and June 2024 were retrospectively evaluated. Fourteen of the patients were male, and twenty-two were female. The average patient age was 64.25 years (range: 43–82). In 26 patients, the surgery was performed on the right shoulder, and in 10 patients, on the left shoulder.
Inclusion Criteria
Patients who underwent arthroscopic repair for full-thickness RCT that did not improve despite at least 3 months of conservative treatment, and who were followed for at least three months after treatment, were included in the study.
Exclusion Criteria
Patients with partial-thickness RCT, irreparable RCT, partially repaired RCT, subscapularis tears, those who underwent mini-open RCR, had glenohumeral arthritis, active infection, or a history of inflammatory diseases such as rheumatoid arthritis were excluded from the study.
Diagnoses were made based on clinical physical examination and Magnetic Resonance Imaging (MRI). Tear sizes were classified as small, medium, or large based on MRI findings. For clinical outcome evaluation, OSS and Quick DASH scores were used. From the patients’ preoperative complete blood count tests, values for neutrophils, lymphocytes, monocytes, and platelets were obtained. Using these, the NLR, PLR, and LMR were calculated. Additionally, the SIRI and the SII were computed.
Surgical Technique
All surgeries were performed by the same surgeon. Under general anesthesia, the patients were positioned in the lateral decubitus position. A posterior viewing portal was established to examine the intra-articular space. Then, the subacromial space was accessed, and subacromial bursectomy was performed, and one or two lateral portals were created to examine the rotator cuff. A double-row repair technique was applied to all. A tenotomy of the long head of the biceps tendon was performed in all patients. Acromioplasty was also performed in all patients, cautiously and without being aggressive.
Postoperative Rehabilitation
The same rehabilitation protocol was applied to all patients postoperatively. Elbow exercises were started on the first postoperative day. Between the 2nd and 6th weeks, shoulder range of motion was achieved through pendulum and passive exercises. After the 6th week, active exercises were initiated, followed by resistance exercises after the 12th week [10].
Statistical Analysis
Normality assumptions were assessed using skewness and kurtosis values. If skewness and kurtosis coefficients were within the range of ±1.5, the data were considered normally distributed [11]. For comparing preoperative and postoperative Quick DASH and OSS scores that followed normal distribution, the paired samples t-test was used. The difference between postoperative and preoperative Quick DASH and OSS scores was calculated to determine the amount of change. For the relationships between changes in scores that did not follow normal distribution and inflammatory mediators, the Spearman rho correlation coefficient was used. For comparing changes in scores according to demographic characteristics, the Kruskal-Wallis H test was used for three-category variables, and the Mann-Whitney U test was used for two-category variables. Analysis results were presented as mean, standard deviation (Mean ± SD), median, minimum, and maximum (Median (min–max)) for quantitative data, and as frequency (n) and percentage (%) for categorical data. A significance level of “p < 0.05” was considered in all calculations. All statistical analyses were performed using IBM SPSS Statistics, version 26.0 (IBM Corp., Armonk, NY, USA) [12].
Ethical Approval
The study was approved by the Ethics Committee of Giresun University Education and Research Hospital Clinical Research Ethics Committee (Date: 2024-12-11, No: 01).
Results
The demographic and clinical data of the patients are presented in Table 1. The mean age of the 36 patients included in the study was 64.25 years (range: 43–82). Of the patients, 61.1% were female. It was observed that in 72.2% of the cases, the operated extremity was the right side. When the tear sizes were examined, it was found that the majority (36.1%) had medium-sized tears. Diabetes was observed in 19.4% of the patients (Table 1).
There was a statistically significant difference between the patients’ preoperative and postoperative Quick DASH scores (p < 0.001). The mean preoperative Quick DASH score was 77.89, whereas the mean postoperative Quick DASH score was 22.02. Likewise, a statistically significant difference was observed between the preoperative and postoperative OSS scores (p < 0.001). The mean preoperative OSS score was 9.75, while the mean postoperative OSS score was 37.17. A significant decrease in DASH scores and a significant increase in OSS scores were observed postoperatively (Table 2).
A statistically significant weak negative correlation was found between the amount of change in OSS scores and patients’ age (r = -0.338, p = 0.044). However, there was no statistically significant correlation between the change in Quick DASH scores and age (p = 0.343). No statistically significant relationship was found between changes in QuickDASH and OSS scores and inflammatory mediators (p > 0.05) (Figure 1).
There was no statistically significant relationship between gender, side of surgery, tear size, or the presence of diabetes and the amount of change in Quick DASH scores (p > 0.05).
Similarly, no statistically significant relationship was found between gender, surgical side, tear size, or the presence of diabetes and the amount of change in OSS scores (p > 0.05).
Discussion
Arthroscopic RCR is widely recognized as an effective method to restore shoulder function and improve patients’ quality of life. However, the postoperative recovery process is influenced by many patient-specific factors. This study shows that Quick DASH and OSS scores significantly improved postoperatively. Current literature supports our clinical findings. Our study is unique in that it is the first to investigate the importance of systemic inflammatory markers in terms of clinical and functional recovery following arthroscopic rotator cuff repair.
In a prospective study conducted by Reddy et al. [13], preoperative factors affecting outcomes after RCR were analyzed in detail. They concluded that age is a significant factor influencing outcomes after RCR. It was found that functional outcomes were better in the younger age group (under 55) compared to the older group (over 65). Consistent with current literature, many publications have shown better results in younger patients, although some authors have found that older patients report higher satisfaction than younger ones [14]. In our study, a statistically significant weak negative correlation was found between patients’ age and changes in OSS scores. However, no statistically significant difference was found between changes in Quick DASH scores and age.
In their study, Chung et al. [15] evaluated factors such as the presence of diabetes, tear size, and side of the tear, and found that diabetic patients had worse outcomes. They also noted that perioperative hypoglycemia had a negative impact, recommending that surgery should be performed after achieving reasonable glycemic control for better results. In our study, no significant difference was found between the presence of diabetes and clinical or functional outcomes. We believe this may be due to the small number of diabetic patients in our study. In terms of tear size and side, they found no effect on clinical and functional outcomes. It is well known that when performed properly by experienced hands, arthroscopic RCR leads to significant improvement regardless of the tear size or side. Our study supports the literature by finding no significant relationship between outcomes and either tear size or surgical side. Accurate analysis of biological and clinical factors affecting surgical outcomes will enhance treatment success. Studies are still ongoing today to increase the success of treatment. In this context, systemic inflammatory markers are gaining attention in the current literature. Markers such as NLR, PLR, LMR, SII, and SIRI are inexpensive, easy to obtain, and accessible through common blood tests. Literature shows that these markers are not only useful in diagnosing disease but also in predicting prognosis and monitoring treatment response.
In the retrospective study conducted by Sun et al. [16], it was reported that the outcomes of arthroscopic rotator cuff repair were favorable regardless of tear size, and that patients with poorer postoperative outcomes had lower preoperative LMR ratios. Based on these findings, it was concluded that preoperative LMR, as an indicator of systemic inflammation, may serve as a prognostic factor for rotator cuff repair. In another retrospective study by Öner et al. [17], 63 patients were evaluated, and it was found that patients with higher preoperative NLR ratios experienced greater postoperative pain and shorter block durations. Accordingly, it was concluded that postoperative pain levels may be predicted through an objective parameter. In our study, however, we found no significant association between preoperative systemic inflammation levels and postoperative functional outcomes.
In a literature review by Islam et al. [18], it was concluded that these indices show promising results in predicting outcomes in high-risk patient groups such as cancer, sepsis, polytrauma, acute ischemic stroke, and acute coronary syndrome, but that their predictive performance is limited when used alone for specific conditions. In a retrospective study by Alsabani et al. [7], on 196 orthopedic surgery patients, it was found that patients with higher SII values had longer hospital stays; however, no significant differences were found in age, gender, ASA score, surgery duration, Intensive Care Unit (ICU) admission, or ICU stay duration. In another retrospective study by Vitiello et al. [19], on 53 patients with periprosthetic joint infection, higher SIRI and MLR values were associated with successful treatment. These indices could guide clinicians in determining the timing of second-stage surgeries, although further studies are needed. In a meta-analysis by Pan et al. [20], on geriatric hip fractures, high NLR and SII values were associated with an increased long-term mortality risk in elderly hip fracture patients. In our study, no significant relationship was found between preoperative systemic inflammation level and clinical and functional recovery.
Limitations
The small sample size and the retrospective design are limitations of our study. Further large-scale, prospective studies are warranted to validate our findings.
Conclusion
In our study, while a significant improvement was observed in the scores following surgery, we concluded that preoperative systemic inflammation levels had no effect on postoperative recovery.
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, and 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.
References
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2. Mihelić R, Jotanović Z, Tudor A, Prpić T, Rakovac I, Šestan B. Surgical treatment of rotator cuff tears. Med Flum. 2013;49(3):280-5.
3. Flurin PH, Landreau P, Gregory T, et al. Réparation arthroscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 576 cas avec contrôle de la cicatrisation [Arthroscopic repair of full-thickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment]. Rev Chir Orthop Reparatrice Appar Mot. 2005;91(Suppl 1):32-42.
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5. Ryvlin J, Kim SW, Hamad MK, et al. The prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune-inflammation index on short- and long-term outcome following surgery for spinal metastases. J Neurosurg Spine. 2023;40(4):475-84.
6. Zhao G, Chen J, Wang J, et al. Predictive values of the postoperative neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio for the diagnosis of early periprosthetic joint infections: a preliminary study. J Orthop Surg Res. 2020;15(1):571.
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19. Vitiello R, Smimmo A, Matteini E, et al. Systemic Inflammation Response Index (SIRI) and Monocyte-to-Lymphocyte Ratio (MLR) are predictors of good outcomes in surgical treatment of periprosthetic joint infections of lower limbs: a single-center retrospective analysis. Healthcare (Basel). 2024;12(9):867.
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Download attachments: 10.4328.ACAM.22876
Mahmut Günay. Impact of preoperative systemic inflammation on clinical recovery following arthroscopic rotator cuff repair. Ann Clin Anal Med 2025;16(Suppl 3):S148-151
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Anxious temperament and anxiety during pregnancy as predictors of preterm birth and low birth weight: A prospective study
Betül Dik, Kazım Gezginç
Department of Obstetrics and Gynecology, Faculty of Medicine,Necmettin Erbakan University, Konya, Turkey
DOI: 10.4328/ACAM.22877 Received: 2025-09-03 Accepted: 2025-10-06 Published Online: 2025-10-14 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S152-155
Corresponding Author: Betül Dik, Department of Obstetrics and Gynecology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey. E-mail: dr.betuldik@hotmail.com P: +90 536 784 31 72 Corresponding Author ORCID ID: https://orcid.org/0000-0001-9460-4793
Other Authors ORCID ID: Kazım Gezginç, https://orcid.org/0000-0002-3441-4960
This study was approved by the Ethics Committee of Necmettin Erbakan University, Meram Faculty of Medicine (Date: 2016-06-23, No: 2016/518)
Aim: This study aimed to examine the association between affective temperament traits and antenatal anxiety with adverse pregnancy outcomes, specifically preterm birth and low birth weight.
Materials and Methods: A prospective observational study was conducted between April and June 2016 at the Obstetrics Outpatient Clinic of Necmettin Erbakan University Faculty of Medicine. A total of 233 healthy pregnant women between the 28th and 30th gestational weeks were included. Anxiety levels and temperament types were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A). Preterm birth was defined as delivery before 37 weeks of gestation, and low birth weight as less than 2500 grams.
Results: Anxiety and depression were reported in 47% and 32% of participants. A weak positive correlation was found between anxious temperament and both gestational age and birth weight (correlation coefficients: 0.217 and 0.189). A statistically significant association was identified between low birth weight and anxious temperament scores (p = 0.021). Additionally, a significant relationship was observed between preterm birth and anxious temperament (p < 0.001). According to the HAD scale, the prevalence of anxiety among participants was 20.86%, while depression was 17.39%.
Discussion: Anxious temperament and antenatal anxiety are associated with a higher risk of preterm birth and low birth weight. These adverse outcomes could potentially be mitigated through early intervention and routine psychological screening during pregnancy.
Keywords: anxiety, low birth weight, maternal anxiety, preterm birth
Introduction
Pregnancy represents a complex biopsychosocial process involving significant physiological, hormonal, and psychological changes. Although it is often considered a natural stage of life, this period may be marked by heightened psychological vulnerability, including emotional reactivity and mood disturbances. Previous research has established associations between prenatal anxiety and depressive symptoms and adverse perinatal outcomes such as preterm birth and low birth weight [1-3].
Preterm labor affects approximately 12-13% of pregnancies in the United States and 5-9% in Europe. While biomedical risk factors for preterm birth and low birth weight have been extensively studied, there is growing recognition of the role played by psychosocial contributors, such as anxiety, depression, and inadequate social support. However, the influence of psychosocial variables, particularly maternal temperament, remains underexplored. Temperament refers to stable emotional and behavioral predispositions that influence an individual’s response to stress.
In accordance with the framework proposed by Akiskal, affective temperament is categorized into five principal subtypes: depressive, hyperthymic, cyclothymic, irritable, and anxious [4]. These subtypes represent stable emotional and behavioral tendencies that have consistently been associated with psychiatric disorders, particularly mood and anxiety disorders. The hyperthymic profile is distinguished by an early onset of elevated mood, reduced sleep duration, and a predominant reliance on denial as a defense mechanism. In contrast, the irritable subtype is characterized by chronic pessimism and a judgmental cognitive style, frequently linked to antisocial personality traits and attention-deficit/hyperactivity disorder. Cyclothymic temperament is marked by rapid and unpredictable mood shifts, signifying a biphasic affective structure. The depressive subtype is delineated by persistent anhedonia, disrupted appetite, pervasive feelings of worthlessness, and suicidal ideation. An anxious temperament is characterized by sustained and excessive worry, often accompanied by somatic symptoms such as tachycardia and chest tightness, with symptoms persisting for more than six months.
Among these affective temperaments, anxious temperament may be particularly relevant during pregnancy due to its association with heightened physiological arousal and increased stress sensitivity. To date, most studies have concentrated on transient anxiety symptoms, whereas the impact of enduring temperamental traits on obstetric outcomes remains insufficiently understood [5,6].
This study investigates the relationship between anxious temperament and adverse obstetric outcomes, with the hypothesis that anxious temperament is a significant predictor of preterm birth and low birth weight. Understanding the role of enduring personality traits, as opposed to transient emotional states, may contribute to early identification and improved perinatal care.
Materials and Methods
Study Design and Participants
This prospective observational study was conducted between April and June 2016 at the Obstetrics Outpatient Clinic of Necmettin Erbakan University Faculty of Medicine. A total of 233 pregnant women between 28 and 30 weeks of gestation were included. Inclusion criteria were absence of physical disabilities, no psychiatric diagnosis or treatment, non-assisted pregnancy, and delivery at the university hospital.
Ethical approval was obtained from the Ethics Committee (Decision No: 2016/518), and written informed consent was received from all participants.
Measurements
Anxiety levels were measured using the Hospital Anxiety and Depression Scale (HADS), originally developed by Zigmond and Snaith and validated in Turkish by Aydemir et al. [7,8].
Affective temperament was assessed using the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A), developed by Akiskal et al. and validated for the Turkish population by Vahip et al. [9,10].
Additionally, a personal information form developed by the researchers was used to collect demographic and clinical information such as maternal age, gestational week, parity, and obstetric history.
Statistical Analysis
All statistical analyses were performed using SPSS 15.0 (SPSS Inc., Chicago, IL, USA). Before performing group comparisons, the normality of continuous variables was tested using the Kolmogorov–Smirnov test and visual methods (histogram, Q-Q plots). Since the data were not normally distributed, non-parametric tests were employed. Descriptive statistics (mean, standard deviation, frequency) were used to summarize data. Differences between the two groups were analyzed using the Mann-Whitney U test. Associations between variables were evaluated using Spearman’s rank correlation coefficient. A p-value of less than 0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Necmettin Erbakan University, Meram Faculty of Medicine (Date: 2016-23-06, No: 2016/518).
Informed Consent
Written informed consent was obtained from all participants after they were informed about the purpose and procedures of the study.
Results
The study included 233 pregnant women aged 17 to 46 years (mean age = 27.57 ± 5.76). Educational attainment varied, with 41.2% having completed primary education, 37.3% secondary education, and 21.5% holding a university degree. Primiparous participants comprised 57.1% of the sample (Table 1).
Preterm birth occurred in 20.6% of cases, and low birth weight was observed in 21.5%. The mean gestational age at delivery was 37.8 ± 3.6 weeks, and the average neonatal birth weight was 2812 ± 710 grams. Affective temperament types were distributed as follows: depressive (12.9%), cyclothymic (1.7%), hyperthymic (0.9%), and irritable (1.7%) (Table 2).
An anxious temperament was significantly associated with both preterm birth (p < 0.001) and low birth weight (p = 0.021). No significant relationships were found between other temperament types and adverse outcomes. A moderate positive correlation was identified between gestational age and birth weight (r = 0.649). According to the Hospital Anxiety and Depression (HAD) scale, the prevalence of anxiety among participants was 20.86%, while the prevalence of depression was 17.39%.
Discussion
Anxious temperament is a stable and enduring personality trait characterized by heightened behavioral and physiological responsiveness to environmental stressors. Individuals with this temperament often exhibit prolonged and exaggerated activation of the hypothalamic-pituitary-adrenal (HPA) axis in response to stress, leading to sustained elevations in cortisol and other glucocorticoids [11]. During pregnancy, chronic HPA axis activation may disrupt maternal-fetal interactions, impacting placental function, fetal growth, and neurodevelopment. Elevated maternal cortisol has been associated with impaired placental enzyme activity, increased uterine contractility, altered fetal HPA axis programming, and changes in inflammatory cytokine profiles, all of which can contribute to adverse obstetric outcomes such as preterm birth and low birth weight [12,13].
Several studies have documented the association between maternal stress, anxiety, and negative perinatal outcomes. Yamamoto et al. identified maternal stress as an independent predictor of reduced gestational age and lower birth weight [14]. Grigoriadis et al. emphasized the predictive role of antenatal anxiety in adverse birth outcomes, highlighting its clinical significance [2]. Dayan et al. reported that elevated state and trait anxiety, along with depressive symptoms, were significantly associated with increased risk of preterm labor [15]. Consistent with these findings, our study indicates that anxious temperament, representing a stable, enduring trait, may be a more reliable predictor of adverse obstetric outcomes than transient mood or anxiety symptoms. In our cohort, anxious temperament was significantly associated with both preterm birth and low birth weight, whereas other temperamental traits and antenatal depressive symptoms did not show such associations. These findings underscore the importance of considering stable personality characteristics in obstetric risk assessments, beyond transient psychological states.
Dole et al. reported that antenatal depression was not significantly correlated with preterm labor, whereas maternal anxiety doubled the risk of preterm delivery [16]. This emphasizes the independent role of anxiety as a psychological risk factor during pregnancy. Our results further reinforce this concept, showing that anxious temperament contributes significantly to negative obstetric outcomes. Importantly, the relationship between anxiety and adverse birth outcomes may be bidirectional: psychological distress may increase the likelihood of preterm delivery, while the experience of prematurity may itself exacerbate maternal anxiety and stress. Prospective longitudinal studies are needed to clarify the temporal and causal relationships underlying these associations.
Mechanistically, anxious temperament may influence pregnancy outcomes through both physiological and behavioral pathways. Physiologically, chronic stress and elevated glucocorticoids can impair placental perfusion, dysregulate inflammatory cytokines, and alter fetal growth trajectories, contributing to prematurity and low birth weight. Behavioral pathways may include maladaptive coping strategies, heightened health-related anxiety, sleep disturbances, poor nutrition, reduced adherence to prenatal care recommendations, and avoidance behaviors, all of which can further exacerbate obstetric risk. Additionally, anxious temperament may interact with other psychosocial factors, such as social support, marital satisfaction, and socioeconomic stressors, amplifying its impact on maternal and neonatal outcomes.
Pregnancy, although a natural life event, represents a period of heightened psychological vulnerability. While most women adapt successfully to the physiological, hormonal, and social changes of pregnancy, a subset may experience excessive emotional burden, resulting in impaired daily functioning, social withdrawal, and increased risk of psychiatric disorders requiring clinical intervention [17]. Identifying women with high-risk temperamental profiles, particularly those with anxious tendencies, provides an opportunity for early intervention, potentially mitigating negative obstetric outcomes.
From a clinical perspective, integrating temperament-focused psychological assessments into routine prenatal care could improve early identification of at-risk women. Structured follow-ups by nurses or midwives, psychoeducational programs focusing on stress management, cognitive behavioral interventions, and peer support networks may collectively reduce emotional distress, enhance maternal well-being, and improve neonatal outcomes. Strengthening family, partner, and community support systems may also buffer the effects of anxious temperament on obstetric risk. Furthermore, early identification of high-risk temperamental profiles may guide targeted interventions, such as referral to mental health services, mindfulness-based stress reduction, or coping skills training, thereby contributing to improved perinatal care [18,19].
In conclusion, our findings indicate a robust association between anxious temperament and adverse obstetric outcomes, including preterm birth and low birth weight. These results highlight the importance of evaluating enduring personality traits alongside transient psychological states during pregnancy. Early identification of women with high-risk temperamental profiles, coupled with targeted interventions and enhanced social support, may reduce psychological distress, improve obstetric outcomes, and promote both maternal and neonatal health. Incorporating temperament assessment into routine prenatal care represents a valuable, evidence-based strategy for comprehensive maternal-fetal care.
Limitations
This study has several limitations that should be acknowledged. Potential confounders such as socioeconomic status, partner support, preexisting medical conditions, and environmental stressors were not fully controlled, and these factors may independently influence maternal psychological well-being and obstetric outcomes. Future research employing multivariate analyses, including logistic regression and structural equation modeling, is warranted to delineate the independent contribution of anxious temperament. Moreover, longitudinal studies that track maternal temperament, psychosocial stressors, and obstetric outcomes across gestation would provide valuable insights into temporal relationships, underlying mechanisms, and potential avenues for intervention.
Conclusion
An anxious temperament is associated with an increased risk of preterm birth and low birth weight. Routine screening for affective temperament traits during pregnancy may help identify at-risk individuals and guide early psychological interventions. Future research should include multivariate analyses to account for confounding factors such as socioeconomic status and social support.
Acknowledgment
The authors would like to thank the participants of this study and the staff of the Department of Obstetrics and Gynecology, Necmettin Erbakan University, for their valuable contributions.
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, and 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.
References
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3. Gelaye B, Sanchez S, Andrade A, Gómez O, Coker A, Dole N. Association of antepartum depression, generalized anxiety, and posttraumatic stress disorder with infant birth weight and gestational age at delivery. J Affect Disord. 2020;262(1):310-6.
4. Akiskal HS, Akiskal KK. The theoretical underpinnings of affective temperaments: implications for evolutionary foundations of bipolar disorder and human nature. J Affect Disord. 2005;85(1):231-9.
5. Buss C, Davis EP, Hobel CJ, Sandman CA. Maternal pregnancy-specific anxiety is associated with child executive function at 6-9 years age. Stress. 2011;14(6):665-76.
6. Schetter CD, Tanner L. Anxiety, depression, and stress in pregnancy: Implications for mothers, children, research, and practice. Curr Opin Psychiatry. 2012;25(2):141-8.
7. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70.
8. Aydemir O, Guvenir T, Kuey L, Kultur S. Validity and reliability of the Turkish version of the Hospital Anxiety and Depression Scale. Turk J Psychiatry. 1997;8(4):280-7.
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10. Akiskal HS, Akiskal KK, Haykal RF, Manning JS, Connor PD. TEMPS-A: Progress towards validation of a self-rated clinical version of the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord. 2005;85(2):3-16.
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Betül Dik, Kazım Gezginç. Anxious temperament and anxiety during pregnancy as predictors of preterm birth and low birth weight: A prospective study. Ann Clin Anal Med 2025;16(Suppl 3):S152-155
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The relationship between the presence of ileus and the clinical picture in cases with gastrointestinal bezoar and its effect on the duration of hospitalization
Vahit Mutlu 1, İsmail Alper Tarım 2, Kadir Yılmaz 3
1 Department of General Surgery, Faculty of Medicine, Uskudar University, İstanbul, Türkiye, 2 Department of General Surgery, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Türkiye, 3 Department of Statistics, Faculty of Medicine, Istanbul Commerce University, İstanbul, Türkiye
DOI: 10.4328/ACAM.22885 Received: 2025-09-10 Accepted: 2025-10-23 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S156-161
Corresponding Author: Vahit Mutlu, Department of General Surgery, Faculty of Medicine, Uskudar University, İstanbul, Türkiye. E-mail: dr.vahitmutlu@gmail.com P: +90 530 211 44 32 Corresponding Author ORCID ID: https://orcid.org/0000-0002-2731-6799
Other Authors ORCID ID: İsmail Alper Tarım, https://orcid.org/0000-0002-6203-2644 . Kadir Yılmaz, https://orcid.org/0000-0003-2568-3015
This study was approved by the Ethics Committee of Üsküdar University Non-Interventional Research Ethics Committee (Date: 2025-07-31, No: 61351342/020-60)
Aim: In this retrospective study, we aimed to investigate the relationship between the presence of ileus and the clinical picture in GI bezoar cases and its effect on the length of hospital stay.
Materials and Methods: The study was conducted by Op. Dr. Vahit Mutlu at various centers used patient files that underwent surgery between January 2007 and December 2020. The study analyzed the patients’ gender, age, symptoms (abdominal pain, nausea, vomiting, gas), duration of complaints, ileus findings, comorbidities, and operation times.
Results: Gender, constipation, DM, CVD, hypothyroid, location, surgical method, recurrence, and duration differences were statistically insignificant (p>0.05). Abdominal pain, nausea & vomiting, and HT were significantly more common in the ileus group (p<0.05). Having ileus was significantly correlated with abdominal pain (r=0.441; p<0.01), nausea & vomiting (r=0.526; p<0.01), and HT (r=0.262; p<0.05). All other baseline characteristics were insignificantly correlated with having ileus (p>0.05). Abdominal pain (B=-1.665; p<0.05) and nausea & vomiting (B=1.937; p<0.01) had a positive and significant effect on ileus. The effect of hypertension was insignificant (p>0.05). In no ileus patients, post-operation hospitalization duration was significantly correlated with age (r=0.432; p<0.05) and surgical method (r=-0.473; p<0.05). In ileus patients, correlations between baseline characteristics and post-operation hospitalization duration were insignificant (p>0.05).
Discussion: Among other symptoms, abdominal pain, nausea, and vomiting were the clinical findings that were multivariately significant in patients with ileus, and the postoperative hospital stay in patients with ileus was independent of age compared to patients without ileus.
Keywords: bezoar, ileus, gastrointestinal diseases
Introduction
Gastrointestinal bezoars (GIB) are clusters of inedible or indigestible material within the digestive tract and are a significant gastrointestinal problem. The word derives from the Persian word “antidote” because bezoars obtained from animals were believed to be antidotes in ancient times [1]. While bezoar formation is rare in the gastrointestinal (GI) system, it is often associated with ulcerative lesions in the stomach, small bowel obstruction, and ileus. Four forms are generally recognized, depending on the substance that forms the bezoar mass: pharmacobezoars, phytobezoars, trichobezoars, and lactobezoars [2].
Furthermore, drug bezoars, which rarely occur due to drug use, also occur [3]. While both computed tomography (CT) and sonography are effective in diagnosing bezoars, CT provides more accurate results, revealing bezoar characteristics [4]. While GI bezoars are sometimes asymptomatic, in some cases they can cause symptoms such as dysphagia, abdominal pain, ulcerative bleeding, hematemesis, and even life-threatening obstruction, gastrointestinal bleeding, or perforation [5]. Symptoms such as nausea, vomiting, and chronic abdominal pain have been reported to be common in pediatric cases [6].
Therefore, bezoars must be removed from the GI tract. Bezoar removal is the most common treatment option. While endoscopic bezoar removal is effective, surgical intervention is necessary in some cases [7]. While endoscopy is generally effective for small bezoars, intestinal obstruction should be considered for those larger than 9 cm in diameter and in older patients [8,9]. Ileus is an intestinal obstruction that represents the loss of the intestines’ normal propulsive capacity. Its pathophysiology involves gas and fluid accumulation with high intraluminal pressure, microcirculatory disorders, and mucosal barrier disorders [10].
This obstruction can be functional and mechanical, but it can also occur postoperatively [11,12-14]. This intestinal obstruction can prevent intestinal function and lead to numerous health problems, particularly in the digestive system. The relationship between bezoars and ileus can be due to the physical obstruction caused by bezoars in ileus, as well as the progression of gastric bezoars to ileus [15].
Furthermore, procedures such as pancreaticojejunal stents have been reported to cause ileus bezoars [16]. Postoperative malnutrition is also among the causes of ileus bezoars [17]. Regardless of the cause, ileus bezoars and ileus obstruction are important issues for individuals’ quality of life and gastrointestinal health.
While studies in the literature report the relationship between ileus obstruction and bezoars, including the transition of bezoars to ileus or other causes, no adequate and comprehensive research has been found to determine which gastrointestinal bezoars cause ileus obstruction [11-15], Furthermore, understanding the impact of not only bezoars located in the ileus but also all other GI bezoars on ileus obstruction may be important for clinical course and treatment management. Therefore, this study aimed to examine the relationship between the presence of ileus and the clinical presentation and its impact on hospitalization duration in patients with GI bezoars.
Materials and Methods
Research Model
The study was designed using a retrospective file review using descriptive and correlational screening models. First, the clinical and baseline parameters of bezoar patients with and without ileus were compared, and then these variables were compared based on the presence of ileus. Finally, a correlational screening model was used using binary logistic regression analysis, with ileus as a dummy variable.
Patients
Patients who underwent bezoar surgery by the researcher between 2007 and 2020 were included. The study was conducted using patient files from various centers operated on by Op. Dr. Vahit Mutlu. According to the power analysis conducted in this context, a total of 64 patient files were targeted, with an effect size of 0.30, an 80% confidence interval, and a significance level of 0.05. Patient inclusion criteria were as follows:
– Patients who have undergone gastric bezoar surgery,
– Age 18 and over,
– Have undergone gastric bezoar surgery,
– Have complete patient data in their files,
– Have no adverse health conditions that could affect the study results
The study’s exclusion criteria were:
– Those under 18 years of age,
– Those with comorbid conditions that could affect the study results,
– Those with relevant data in their patient files
Abdominal surgery, abdominal and inguinal hernias, intestinal diseases, and gastrointestinal system disorders are the most commonly reported causes of ileus in the literature [11-14]. Therefore, when evaluating patients for ileus, comorbidities and patient epicrisis reports were also examined along with these parameters.
Statistical Methods
Nominal and ordinal data were described using frequency analysis, and measurement data were described using mean, standard deviation, median, and range of variation. Fisher’s Exact and Chi-Square tests were used for differences between nominal and ordinal data. The Kolmogorov-Smirnov test was used to determine the conformity of measurement data to a normal distribution. The Independent samples t-test was used for pairwise differences in normally distributed parameters, and the Mann-Whitney U test was used for non-normally distributed data. Spearman’s rho correlation analysis was performed for relational screening analysis. Binary Logistic Regression analysis was performed for effect analysis to minimize linearization deviations [18,19]. All analyses were performed using SPSS 25.0 for Windows at a significance level of 0.05 and a 95% confidence interval.
Ethical Approval
This study was approved by the Ethics Committee of Üsküdar University Non-Interventional Research Ethics Committee (Date: 2025-07-31, No: 61351342/020-60).
Results
The mean age of all the bezoar group was 63.10±12.60, with 27 to 84. The mean age of the ileus group was lower, but the difference was insignificant (p > 0.05). 61.3% of the non-ileus group and 48.8% of the ileus group were females. 54.8% of the non-ileus group had abdominal pain, 22.6% had nausea and vomiting, 12.9% had constipation, 16.1% had DM, 9.7% had HT, 6.5% had CVD, and 67.7% had abdominal surgery history. 92.7% of the non-ileus group had abdominal pain, 75.6% had nausea and vomiting, 29.3% had constipation, 24.4% had DM, 31.7% had HT, 17.1% had CVD, and 51.2% had abdominal surgery history. Gender, constipation, DM, CVD, hypothyroid, location, surgical method, recurrence, and duration differences were statistically insignificant (p > 0.05). Abdominal pain, nausea & vomiting, and HT were significantly more common in the ileus group (p < 0.05) (Table 1).
Having ileus was significantly correlated with abdominal pain (r = 0.441; p < 0.01), nausea & vomiting (r = 0.526; p < 0.01), and HT (r = 0.262; p < 0.05). All other baseline characteristics were insignificantly correlated with having ileus (p > 0.05).
Binary logistic regression for effects of significantly correlated factors on ileus results showed that abdominal pain (B = -1.665; p < 0.05) and nausea & vomiting (B = 1.937; p < 0.01) had a positive and significant effect on ileus. The effect of hypertension was insignificant (p > 0.05) (Table 2).
In no ileus patients, post-operation hospitalization duration was significantly correlated with age (r = 0.432; p < 0.05) and surgical method (r = -0.473; p < 0.05). In ileus patients, correlations between baseline characteristics and post-operation hospitalization duration were insignificant (p > 0.05) (Table 3).
In both groups, post-operation hospitalization duration was significantly higher in Enterotomy (p<0.05) (Figure 1).
Discussion
This study aimed to examine the relationship between the presence of ileus and the clinical presentation in patients with GI bezoars and its impact on length of stay. Data from 71 patients with and without ileus were analyzed. Among other symptoms, abdominal pain, nausea, and vomiting were the most significant clinical findings in patients with ileus, and postoperative length of stay in patients with ileus was independent of age compared to those without ileus.
Bezoars are inedible, indigestible foreign body masses within the stomach or gastrointestinal system and can often cause problems such as ulcerative colitis, bleeding, and indigestion [1-4]. Ileus refers to the obstruction of the intestines, resulting in loss of propulsion [10-14]. Ileus occurring in the intestines prevents the intestines from performing their normal digestive functions and can lead to gastrointestinal problems [12-14]. Abdominal surgery is one of the most important known causes of ileus, and factors such as abdominal and inguinal hernias, intestinal diseases, and gastrointestinal system disorders are among the important causes of ileus [11-14]. Biffl and Moore reported that bezoar migration caused ileus in patients with a nidus bezoar [20]. Dedes et al. reported that bezoars formed after gastric resection surgery due to malnutrition, which in turn caused ileus. Dikicier et al. reported that there was no significant difference between ileus caused by bezoars and ileus caused by other causes, and that bezoars may be associated with ileus in 0.4% to 4% of cases [21,22]. Wang et al. reported how to visualize bezoar-induced obstruction and ileus and their similarity to normal ileus [23]. However, these studies only examined the cause-and-effect relationship between ileus and bezoar; non-bezoar-induced ileus and bezoar were not adequately examined.
In our study, Gender, constipation, DM, CVD, hypothyroid, location, surgical method, recurrence, and duration differences were statistically insignificant. Abdominal pain, nausea & vomiting, and HT were significantly more common in the ileus group. Having ileus was significantly correlated with abdominal pain, nausea & vomiting, and HT. All other baseline characteristics were insignificantly correlated with having ileus. Abdominal pain, nausea, and vomiting had a positive and significant effect on ileus. The effect of hypertension was insignificant. In no ileus patients, post-operation hospitalization duration was significantly correlated with age and surgical method. In ileus patients, correlations between baseline characteristics and post-operation hospitalization duration were insignificant.
Limitations
The most significant limitation of the study is the varying definitions of bezoar and ileus, resulting in varying sources and definitions in the literature, as well as the diverse clinical characteristics of the patients. Furthermore, limited information regarding the physical formation process and effects of bezoars, their diagnosis, and their mechanism of action are among the limitations of the study.
Another significant limitation of the study is the lack of history and sufficient knowledge of potential risk factors in bezoar patients. Although overall health literacy levels are increasing, there are still gaps in knowledge regarding health-related follow-up, particularly regarding nutrition.
Contribution to Literature and Clinical Practice
While studies on bezoars in the literature generally report the clinical course and treatment of patients with bezoars, there are insufficient multicenter, long-term studies investigating the relationship with ileus. From a clinical perspective, it would be beneficial to demonstrate this relationship for the management of ileus and bezoars. Therefore, this study is important because it contributes positively to the literature.
The research’s contribution to clinical practice is that it highlights the relationship between bezoars and ileus, suggesting a clinical suspicion of ileus in patients with abdominal pain and nausea, and vomiting, even if symptoms are not directly observed. Further research may establish a direct relationship between ileus and these variables.
Conclusion
Among other symptoms, abdominal pain, nausea, and vomiting were the most significant clinical findings in patients with ileus, and the postoperative length of stay in patients with ileus was independent of age compared to those without ileus. Although there were similar symptoms between ileus and constipation, multivariate analysis revealed abdominal pain, nausea, and vomiting as indicators of ileus. While clinical diagnosis is easy and possible when an obvious obstruction is evident in ileus, clinical diagnosis can be difficult when the intestines lose their ability to propel. In this regard, abdominal pain and nausea, and vomiting are particularly important.
Although postoperative length of stay was not directly associated with ileus, the lack of correlation between postoperative length of stay and age in patients with ileus suggests that outcomes from bezoar surgery in patients with ileus may differ significantly with larger sample sizes. Therefore, studies with larger samples and cross-comparisons across different centers may be conducted.
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, and 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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12. Luckey A, Livingston E, Taché Y. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138(2):206-14.
13. Harnsberger CR, Maykel JA, Alavi K. Postoperative ileus. Clin Colon Rectal Surg. 2019;32(3):166-70.
14. Baig MK, Wexner SD. Postoperative ileus: A review. Diseases of the colon and rectum. 2004;47(4):516-26.
15. Chen HW, Chu HC. Migration of gastric bezoars leading to secondary ileus. Intern Med. 2011;50(18):1993-5.
16. Lwin TM, Leigh N, Iskandar ME, Steele JG, Wayne MG, Cooperman AM. Rare, uncommon, and unusual complications after pancreaticoduodenal resection. Surg Clin North Am. 2018;98(1):87-94.
17. Llobera ND, Pasquini MT, Reberendo MJ, Chapela SP, Maurette R. Enteral nutrition-related small bowel bezoar: a case report and literature review. Anaesthesiol Intensive Ther. 2023;55(5):377-81.
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Vahit Mutlu, İsmail Alper Tarım, Kadir Yılmaz. The relationship between the presence of ileus and the clinical picture in cases with gastrointestinal bezoar and its effect on the duration of hospitalization. Ann Clin Anal Med 2025;16(Suppl 3):S156-161
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D-lactate and SCUBE-1 levels in critically ill patients
Bensu Bulut 1, Ramiz Yazıcı 2, Dilek Atik 3, Utku Murat Kalafat 2, Hüseyin Mutlu 4, Medine Akkan Öz 1, Murat Genç 5, Başar Cander 6, Zekeriya Uykan 7
1 Department of Emergency Medicine, Health Science University, Gulhane Training and Research Hospital, Ankara, Turkey, 2 Department of Emergency Medicine, Health Science University, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul,Turkey, 3 Department of Emergency Medicine, Faculty of Medicine, Karamanoğlu Mehmetbey University, Karaman, Turkey, 4 Department of Emergency Medicine, Aksaray University, Aksaray Training and Research Hospital, Aksaray, Turkey, 5 Department of Emergency Medicine, University of Health Sciences, Ankara Training and Research Hospital, Ankara, Turkey, 6 Department of Emergency Medicine, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey, 7 Department of Engineering and Technology, Faculty of Electrical Engineering, American University of the Middle East, Egaila, Kuwait
DOI: 10.4328/ACAM.22887 Received: 2025-09-10 Accepted: 2025-10-13 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S162-166
Corresponding Author: Bensu Bulut, Department of Emergency Medicine, Gulhane Training and Research Hospital, Health Science University, Ankara, Turkey. E-mail: bensu.bulut@gmail.com P: +90 553 181 93 62 Corresponding Author ORCID ID: https://orcid.org/0000-0002-5629-3143
Other Authors ORCID ID: Ramiz Yazıcı, https://orcid.org/0000-0001-9210-914X . Dilek Atik, https://orcid.org/0000-0002-3270-8711 . Utku Murat Kalafat, https://orcid.org/0000-0003-1749-8098 . Hüseyin Mutlu, https://orcid.org/0000-0002-1930-3293 . Medine Akkan Öz, https://orcid.org/0000-0002-6320-9667 . Murat Genç, https://orcid.org/0000-0003-3407-1942 . Başar Cander, https://orcid.org/0000-0002-3308-5843 . Zekeriya Uykan, https://orcid.org/0000-0002-9526-9218
The present study was approved by the ethics committee of Kanuni Sultan Suleyman Training and Research Hospital (Date: 2019-01-11, No: 2019-1/11)
Aim: Critical illness in the emergency department (ED) of a hospital requires rapid assessment and intervention. This study aimed to investigate the diagnostic and prognostic levels of D-lactate and SCUBE-1 in critically ill patients being admitted to the ED.
Material and Methods: This prospective observational case-control study consisted of 45 critically ill patients and 45 healthy controls. Serum D-lactate and SCUBE-1 levels were measured upon admission to the ED, and clinical scores (APACHE II, GCS, RTS) were calculated for critically ill patients. The primary outcome was 28-day mortality.
Results: Both D-lactate and SCUBE-1 levels were significantly higher in critically ill patients as compared to controls (p<0.001). In multivariate logistic regression analysis, SCUBE-1 (OR=2.16, 95%CI:1.65-3.43, p<0.001) and D-lactate (OR=1.86, 95%CI:1.11-2.41, p=0.012) were independent predictors of mortality. ROC analysis revealed that SCUBE-1 >43 ng/mL predicted mortality with 56.2% sensitivity and 72.4% specificity, while D-lactate >279 mmol/L showed 51.5% sensitivity and 68.3% specificity. D-lactate and SCUBE-1 levels are promising biomarkers for the prediction of mortality in critically ill ED patients.
Discussion: These markers, when used in conjunction with clinical scoring systems, may prove useful when risk stratification and guide management decisions are made in the ED.
Keywords: D-lactate, SCUBE-1, critical illness, emergency department, mortality biomarkers
Introduction
A critically ill patient is defined as having unstable basic vital functions, is receiving supportive treatment, or whose general condition is expected to deteriorate [1,2]. With the rise in the number of patients admitted to emergency departments (ED), there has been a corresponding increase in the number of critically ill patients, and reports indicate a 79% rise in the proportion of critically ill patients among all ED admissions [3,4]. Survival in these patients is primarily determined by the severity of the acute illness upon admission and the quality of care provided throughout the course of the treatment, [5,6]. Rapid assessment and intervention are crucial, and many scoring systems have been developed to assist in determining treatment priorities [1, 3]. The role of the ED is resuscitation and initial assessment in the care of critically ill patients, rather than providing continuous longitudinal care, [7]. Lactic acid exists as two optical enantiomers: L-lactic acid and D-lactic acid, [8, 9]. Humans normally produce very little D-lactate because they lack the enzyme D-lactate dehydrogenase (D-LDH) [8,10]. However, D-lactate can be produced endogenously in limited amounts in tissues such as the brain and the lens of the eye via the methylglyoxal pathway [8,11]. Furthermore, D-lactate is produced in certain amounts by gastrointestinal bacteria, but blood levels increase due to antibiotic use, short bowel syndrome, inflammatory bowel disease (IBD), metabolic disorders, autoimmune conditions, sepsis, and psychiatric and neurological diseases that cause an increase in D-lactate-producing bacteria, such as dysbiosis [8-10,12]. D-lactate may be exogenously increased as a result of fermented foods, propylene glycol-containing drugs, or Ringer’s lactate use [8,13]. However, when D-lactate is formed, it is metabolized to pyruvate by D-2-hydroxy acid dehydrogenase (D-2-HDH) in the liver and kidney [8,12,13].
SCUBE-1 (signal peptide-CUB-epidermal growth factor [EGF] domain-containing protein 1) is a cell surface glycoprotein expressed during early embryogenesis and found in platelets and endothelial cells, [14-16]. SCUBE-1 is involved in the process of developmental and pathologic angiogenesis [14-17], and has been demonstrated by in situ hybridization in vascular endothelial cells. It is abundant in several highly vascularized tissues, such as the liver, kidney, lung, spleen, and brain[14,16,18], and is produced and stored in platelets [18]. Plasma SCUBE-1 has been shown to bind platelets together to form thrombi and plays a critical role in arterial thrombosis, [16,17,18]. Clinical studies have shown that plasma SCUBE-1 levels increase in ischemic conditions, such as acute coronary syndrome and acute ischemic stroke, and may be a biomarker of platelet activation [14,15,18].
Many scoring systems have been developed to determine the severity of illness and predict mortality in critically ill patients. However, no clinical tool has been validated to predict disease severity and mortality among patients considered to require critical care in the ED. Due to this shortcoming, researchers have turned to finding new biochemical markers for strengthening scoring systems. This study aims to contribute to this research by investigating the efficacy of serum D-lactate and SCUBE-1 levels in predicting disease severity and prognosis in critically ill patients admitted to the ED.
Materials and Methods
Study Design and Setting
This observational and prospective study was conducted in the Emergency Department (ED) of Kanuni Sultan Süleyman Training and Research Hospital, a tertiary care center. The ED includes a Level 3 emergency intensive care unit comprising seven beds and managed by emergency medicine specialists, where all patients enrolled in the study were monitored. The study period spanned from July 2019 to January 2020, during which the ED admitted approximately 30,000 patients per month. All trauma patients presenting to the ED were treated according to Advanced Trauma Life Support (ATLS) protocols, while non-trauma patients were managed in line with Advanced Cardiac Life Support (ACLS) guidelines. Informed consent was obtained from the relatives of all patients. The study was based on blood samples collected from critically ill patients at the time of initial presentation, and the patient flow chart is shown in Figure 1.
Various data were recorded, including patients’ demographic characteristics, medical history, vital signs, laboratory findings, and, for trauma patients, the mechanism of injury, Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation (APACHE) II score, Revised Trauma Score (RTS), shock index, and mortality status. Trauma scoring systems such as the Glasgow Coma Score (GCS), Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) were utilized to assess the severity of patients’ clinical conditions. Critical patients were categorized into seven groups based on their ED diagnoses: central nervous system, cardiovascular system, respiratory system, gastrointestinal system/metabolic, sepsis, trauma, and others. Clinical outcomes of these patients (ED length of stay, intensive care unit (ICU) or ward admission, ED and ICU mortality) were also documented.
Treatment for critical patients was initiated according to ACLS/ATLS protocols, and blood samples collected upon ED admission were placed in Ethylenediaminetetraacetic acid (EDTA) tubes. After centrifugation at 2800 rpm for 20 minutes at 4°C, plasma samples were transferred to Eppendorf tubes and stored at -80°C until analysis. Scube-1 and D-lactate levels were measured in duplicate using enzyme-linked immunosorbent assay (My-BioSource MBS044526; MyBioSource, Inc., San Diego, California). Scube-1 levels were expressed in nanograms (ng)/mL, while D-lactate levels were expressed in millimoles (mmol)/L.
Statistical Analysis
In the study data, numerical values were expressed as mean ± standard deviation and minimum-maximum values. The Kolmogorov-Smirnov test was used to evaluate the normal distribution of all variables. The Chi-squared correspondence test was used to evaluate nominal data between groups, while the Student’s t-test was used for parametric variables in the clinical study. The Kruskal-Wallis H test and the Mann-Whitney U test were used in statistical evaluations according to whether the nonparametric variables were categorical (nominal or ordinal) or numerical independent groups. The Spearman correlation test was used to evaluate the correlation between D-lactate and SCUBE-1 levels in the data set, according to mortality. These results of the critical care patients were evaluated with the ROC (Receiver Operating Characteristics) curve according to the clinical results of D-lactate and SCUBE-1 blood values. The regression analysis method was used to assess the effect of patient diagnoses and previous diseases on SCUBE-1 and D-lactate levels in the data set. The results were evaluated for a significance level of p < 0.05. According to the sample calculation made with G-Power, assuming an alpha error of 5%, a working power of 80%, and a loss of 20%, it was determined that 90 patients would be sufficient for the study.
Ethical Approval
The present study was approved by the ethics committee of Kanuni Sultan Suleyman Training and Research Hospital (Date: 2019-01-11, No: 2019-1/11).
The study was registered in ClinicalTrials.gov (NCT06704438).
Results
During the study period, 80 volunteer critically ill patients were assessed for eligibility, and 35 were excluded for the following
reasons: 13 refused to participate, eight could not calculate the scoring system, seven had incompatible blood samples, five lacked data, and two were under 18 years of age. The final sample consisted of 45 critically ill patients (25 (55.6%) males and 20 (44.4%) females) and 45 healthy volunteers in the control group (23 (51.1%) males and 22 (48.9%) females). The mean age of the critically ill patients was 64.8±21.4 years. The baseline characteristics of the participants are shown in Table 1. The most common diagnoses in critically ill patients were respiratory system diseases (n:15) and trauma (n:11). 28-day mortality was 40% (n:18). APACHE II score was 18.6±9.1 in deceased critically ill patients, which was higher than in critically ill patients (16.3±8.2 in critically ill patients). SCUBE-1 level at admission was 124.5±85.6 in the deceased group and 53.3±9.8 in the surviving group, which was significantly lower (p< 0.001). The diagnoses, clinical scores, and laboratory values of critically ill patients are shown in Table 1. Variables found to be significant in univariate logistic regression analysis were included in the multivariate logistic regression model. In multivariate logistic regression analysis, SCUBE-1 (OR=2.16, 95%CI:1.65-3.43, p<0.001), D-lactate (OR=1.86, 95%CI:1.11-2.41, p=0.012), GCS (OR=0.68, 95%CI:0.57-0.84, p<0.001), and APACHE II (OR=1.39, 95%CI:1.06-3.79, p=0.031) scores were independent predictors of mortality in critically ill patients in the ED (Table 2). The cut-off value of D-lactate and SCUBE-1 levels for predicting mortality in critically ill patients was determined using Receiver Operating Characteristics (ROC) analysis (Fig. 2). It was discovered that an SCUBE-1 level of more than 43 ng/mL predicted mortality in critically ill patients with 56.2% sensitivity and 72.4% specificity.
Discussion
Rapid assessment and intervention are important to reduce mortality in critically ill patients admitted to the ED, [10]. In the ED, deterioration of the critical patient’s condition or unexpected death usually precedes abnormalities in vital signs [3,4]. The causes of death are potentially treatable, and treatment is effective if intervention is made in time, [3,4]. Early diagnosis is therefore crucial for early intervention. While many laboratory parameters, scoring systems, and imaging methods have, to date, been used to determine possibly fatal diagnoses in critically ill patients [2,4,6,10], no single valid method is yet available. As the use of new markers, together with scoring systems, may be useful in terms of prognosis prediction and treatment management, this study investigated the effect of D-lactate and SCUBE-1 levels on the survival of critically ill patients in the ED until discharge. To our knowledge, this is the first study to examine D-lactate and SCUBE-1 levels as prognosis predictors in critically ill patients.
The study has determined that both D-Lactate and SCUBE-1 levels were statistically significantly higher in critically ill patients when compared to the control group (p<0.001). SCUBE-1 (AUC=0.725, 95% CI: 0.491-0.839) predicted mortality in critically ill patients with 56.2% sensitivity and 72.4% specificity, while D-lactate (AUC=0.698, 95% CI: 0.521-0.874) predicted mortality with 51.5% sensitivity and 68.3% specificity. These results suggest that both D-lactate and SCUBE-1 are predictive markers for diagnosis and mortality in critically ill patients in the ED. In critically ill patients, bacterial translocation and epithelial damage usually occur as a result of inadequate oxygenation of the intestinal mucosa, leading to increased production and absorption of D-lactate [8,11]. Restrepo-Álvarez et al. emphasized that intestinal permeability increased in patients with sepsis [19]. Murray et al. reported that D-lactate levels increased in patients with intestinal ischemia, and Poeze et al. and Jørgensen et al. showed that D-lactate increased in critically ill patients with sepsis and was associated with the severity of the disease [8,20-22]. Other studies have also demonstrated that D-lactate increased due to intestinal ischemia after abdominal surgery, [23]. This study has determined that D-lactate levels were high in critically ill patients and were even an indicator of mortality. These results suggest that intestinal ischemia is present in critically ill patients with higher D-lactate levels.
It has been suggested that SCUBE-1 is abundantly expressed in human platelets, stored in α-granules, and released when the platelets are stimulated, [17,18]. In a study by Dai et al., it was shown that SCUBE-1 levels increased in 152 patients with cerebral and coronary thrombi, indicating its active role in thrombus formation. Other animal studies have also demonstrated that SCUBE-1 is involved in arterial thrombus formation, [18]. Toprak et al. reported that SCUBE-1 levels were significantly higher in 553 COVID-19 patients with a pro-thrombotic predisposition as compared to a control group, [15]. Additionally, Erdogan et al. found that SCUBE-1 levels correlated with the severity of sepsis and served as an indicator of mortality in a study of 187 patients with sepsis in which there was an imbalance in coagulation and fibrinolytic systems [24]. This study has also found elevated SCUBE-1 levels in critically ill patients compared to healthy subjects, supporting such elevated levels as a predictive marker of mortality. These results suggest that there is an impairment in coagulation and fibrinolytic systems in critically ill patients admitted to the ED.
In a study conducted across 90 hospitals with 50,322 critically ill patients, Chalfin et al. found that the APACHE II score of deceased patients was 16.3 points higher than that of survivors [3]. Many similar studies have also reported that a high APACHE II score is an indicator of mortality [2,5,6]. Consistent with these results, our study also identifies a high APACHE II score as an indicator of mortality in critically ill patients admitted to the ED.
The most significant aspect of our study is that it is the first prospective study to investigate D-lactate and SCUBE-1 as predictive factors for mortality in critically ill patients who have been admitted to an ED.
However, the study does have certain limitations, the first being that the study was conducted at a single center with a relatively small number of patients. A second limitation was that only D-lactate and SCUBE-1 levels at the time of ED admission were examined, and no controls were included. Thirdly, other commonly used scoring systems were not considered. Lastly, the relationship between D-lactate and SCUBE-1 was not explored with the scoring systems and mortality in critically ill patients.
Limitations
This study has several limitations. First, the relatively small sample size may restrict the generalizability of the findings. Second, it was conducted in a single-center setting, which may limit the external validity of the results. Third, critically ill patients inherently exhibit heterogeneity in comorbid conditions, therapeutic approaches, and disease severity. Additionally, the cross-sectional nature of the study does not allow for establishing causality; however, elevated D-lactate and SCUBE-1 levels may serve as prognostic indicators of increased mortality and support earlier ICU admission decisions in critically ill patients. Therefore, larger multicenter prospective studies are required to validate the diagnostic and prognostic value of D-lactate and SCUBE-1 in critically ill patients.
Conclusion
In conclusion, it was found that D-lactate and SCUBE-1 are predictive markers for diagnosis and mortality in critically ill patients in EDs. D-lactate and SCUBE-1 may be promising markers for predicting mortality in critically ill patients and could be used in conjunction with scoring systems in EDs and intensive care units. However, more extensive prospective studies are needed to confirm these findings.
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, and 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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15. Toprak K, Kaplangoray M, Palice A, et al. SCUBE1 is associated with thrombotic complications, disease severity, and in-hospital mortality in COVID-19 patients. Thromb Res. 2022;220:100-6.
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Bensu Bulut, Ramiz Yazıcı, Dilek Atik, Utku Murat Kalafat, Hüseyin Mutlu, Medine Akkan Öz, Murat Genç, Başar Cander, Zekeriya Uykan. D-lactate and SCUBE-1 levels in critically ill patients. Ann Clin Anal Med 2025;16(Suppl 3):S162-166
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Anesthetic management in pediatric cardiac reoperations: Experiences from our institution
Serife Ozalp, Funda Gumuş Ozcan
Department of Anaesthesiology and Reanimation, Istanbul Health Sciences University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22888 Received: 2025-09-11 Accepted: 2025-10-13 Published Online: 2025-10-21 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S167-171
Corresponding Author: Serife Ozalp, Department of Anaesthesiology and Reanimation, Istanbul Health Sciences University Basaksehir Cam and Sakura Hospital, Istanbul, Turkey. E-mail: serife.kaplan@hotmail.com P: +90 212 909 60 00 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6762-895X
Other Authors ORCID ID: Funda Gumuş Ozcan, https://orcid.org/0000-0003-0641-7977
This study was approved by the Ethics Committee of University of Health Sciences, Türkiye, Basaksehir Cam and Sakura City Hospital (Date: 2025-03-19, No: 103)
Aim: Redo cardiac surgery in pediatric patients is associated with increased anesthetic complexity due to adhesions, altered mediastinal anatomy, increased bleeding risk, and arrhythmia susceptibility. Given the scarcity of literature on this high-risk group, this study aims to present our institutional experiences in the anesthetic management of pediatric cardiac reoperations.
Materials and Methods: This retrospective single-center study included 282 pediatric patients who underwent redo cardiac surgery for congenital heart disease between January 2021 and January 2025. Data collected included demographic characteristics, anesthetic techniques, perioperative complications, and postoperative outcomes.
Results: The mean age was 30.82 ± 47.32 months, and 56.02% of patients were extubated in the operating room. In 101 patients (>10 kg), backup femoral sheets were pre-inserted to serve as a guide for potential emergency femoral cannulation during cardiopulmonary bypass (CPB). Intraoperative cardiac or vascular injuries occurred in 4 patients (1.41%), and emergency CPB via peripheral access was initiated in 3 cases. Ventricular fibrillation requiring defibrillation occurred in 18 patients (6.38%), while 3 patients (1.06%) developed supraventricular tachycardia requiring cardioversion. ROTEM-guided bleeding management was utilized in 21 patients (7.44%), with cryoprecipitate and fibrinogen replacement required in 70.21% and 44.32% of patients, respectively. Postoperatively, ECMO was required in 25 patients (8.86%), and the mean ICU stay was 17.18 ± 19.69 days. The overall mortality rate was 12.05%.
Discussion: Redo cardiac surgery in pediatric patients presents considerable anesthetic challenges. Our findings underscore the importance of meticulous preoperative planning, intraoperative vigilance, and targeted hemostatic and arrhythmia management strategies.
Keywords: congenital cardiac surgery, cardiac reoperation, anesthetic management
Introduction
Patients with complex congenital heart disease often require multiple cardiac interventions and median sternotomies throughout their lifetime. With the increasing life expectancy of this patient population, redo sternotomy has become an increasingly common procedure. Compared to primary cardiac surgeries, the anesthetic management of these patients requires special attention due to a higher risk of complications [1,2]. In patients undergoing redo sternotomy, factors such as adhesions, anatomical alterations in mediastinal structures, arrhythmias, and increased bleeding risk are the main challenges complicating anesthetic care.
During the initial phase of surgery, from skin incision to the initiation of cardiopulmonary bypass (CPB), injuries to cardiac and vascular structures and the phrenic nerve, as well as bleeding and severe arrhythmias, can lead to fatal complications and require meticulous attention. In patients likely to undergo a technically difficult and high-risk resternotomy, peripheral vessels may be used to initiate cardiopulmonary bypass. Several peripheral cannulation sites have been identified, and the femoral vessels have been shown to be safe and effective options for cannulation [3,4]. However, in pediatric patients, the available cannulation sites are limited [5,6]. Due to multiple previous surgical interventions, femoral or axillary vessels may be too small, stenotic, or completely occluded. These limitations can pose challenges for the anesthesia team during preoperative central venous catheterization or when establishing backup peripheral cannulation access. Additionally, due to the risk of severe bleeding, the anesthesia team must be well-prepared in terms of blood products and transfusion management.
Anesthesia departments involved in pediatric cardiac surgery should develop specific approaches and protocols tailored to this high-risk population. However, despite this need, there is a limited number of studies in the literature focusing specifically on this patient group. In our study, we aimed to retrospectively evaluate our institutional anesthesia experience in pediatric patients who underwent redo cardiac surgery between January 2021 and January 2025. By presenting the characteristics of our clinical practice, we seek to contribute to the existing literature and identify potential areas for improvement.
Materials and Methods
This single-center, retrospective study was conducted between January 1, 2021, and January 1, 2025, in the Departments of Anesthesiology and Reanimation and Pediatric Cardiac Surgery at our institution. All pediatric patients who underwent reoperative cardiac surgery due to congenital heart disease were included, regardless of sex.
Exclusion Criteria
• Age over 18 years
• Patients undergoing emergency surgery
• Incomplete or missing data
After obtaining written informed consent, a routine pre-anesthetic evaluation was performed. A total of 282 patients (both male and female) were included in the study.
Out of 450 total patients initially screened, 52 were excluded due to missing data, 17 were older than 18 years, and 99 represented emergency cases. After applying these exclusion criteria, 282 patients met the eligibility requirements and were ultimately included in the final analysis.
Intraoperative Monitoring and Anesthetic Management
Upon arrival in the operating room, all patients were routinely monitored with electrocardiography (ECG), non-invasive blood pressure, and pulse oximetry before the induction of anesthesia. Additionally, due to the increased risk of sudden and serious arrhythmias requiring defibrillation or cardioversion in this patient group, external defibrillator pads were applied, and ECG monitoring was also performed via a separate defibrillator monitor.
As an extra precaution, one unit of erythrocyte suspension (ES) was prearranged and kept available in the operating room in anticipation of severe or massive bleeding. The standard anesthetic induction protocol included:
• Midazolam (0.1 mg/kg)
• Fentanyl (1 µg/kg)
• Ketamine (1 mg/kg)
• Rocuronium bromide (0.6 mg/kg)
• In addition, cefazolin (30 mg/kg IV) and methylprednisolone (3 mg/kg IV) were administered as prophylactic agents. As a non-standard measure, a tranexamic acid infusion (2 mg/kg/hour) was administered in this patient group.
Invasive arterial blood pressure monitoring was established via radial or femoral artery cannulation. Central venous access was obtained through the internal jugular or subclavian vein, or the femoral vein when necessary. In patients over 10 kg, based on institutional consensus between perfusionists and surgeons, backup 5F femoral arterial and venous sheaths were pre-inserted to facilitate emergency femoral cannulation in preparation for cardiopulmonary bypass (CPB). Ultrasound guidance was used for sheath placement, and vessel diameters were measured and documented by the anesthesiology team.
Evaluation Parameters
• Demographic data (age, sex, body weight, diagnosis, prior surgeries)
• Anesthetic agents used
• Duration of anesthesia and CPB
• Perioperative complications (injuries, bleeding, arrhythmias, defibrillation requirements and characteristics)
• Emergency CPB using backup peripheral cannulation
• Excessive bleeding requiring ROTEM-guided intervention, use of the cell-saver
• Postoperative mechanical ventilation, ECMO requirement, ICU length of stay
• Morbidity and mortality rates
Statistical Analysis
Statistical analysis was performed using NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA). Descriptive statistics (mean, standard deviation, median, frequency, percentage, minimum, maximum) were used to evaluate the data. The Shapiro-Wilk test and graphical methods were used to assess the normality of distribution. The Mann-Whitney U test was used for between-group comparisons of non-normally distributed variables, and the Wilcoxon Signed Ranks test was used for pre- and postoperative comparisons. Pearson’s chi-square test was used to evaluate categorical variables. A p-value < 0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of the University of Health Sciences, Türkiye, Basaksehir Cam and Sakura City Hospital (Date: 2025-03-19, No: 103).
Results
A total of 282 pediatric patients who underwent cardiac surgery were included in this study. Among these, 170 (60.3%) were male and 111 (39.4%) were female. The mean age was 30.82 ± 47.32 months; the average weight was 12.23 ± 13.85 kg, and the mean height was 81.21 ± 31.51 cm. The average total anesthesia time was 424.02 ± 116.08 minutes, and the average CPB time was 128.16 ± 78.83 minutes. The demographic and clinical characteristics of the patients are summarized in Table 1. Additionally, 40 patients (14.2%) had a genetic syndrome. A wide variety of complex surgical procedures were performed. The distribution of surgical procedures is shown in Table 2. In 101 patients weighing over 10 kg, 5F backup femoral arterial and venous sheaths were inserted and kept available for emergency use. Intraoperative complications included atrial injury in 1 patient, ventricular injury in 1, pulmonary artery injury in 1, and aortic injury in 1. In 3 of these cases, emergency CPB was initiated using peripheral cannulation and the procedures continued under bypass support.
Due to the high risk of life-threatening arrhythmias, external defibrillator pads were routinely applied, and the ECG was monitored on a separate defibrillator screen. In cases of ventricular fibrillation, defibrillation was initiated at 2 to 4 joules/kg using external pads, and subsequent shocks were applied with gradually increased energy levels. A total of 18 patients (6.38%) developed ventricular fibrillation requiring defibrillation, and supraventricular tachycardia requiring cardioversion was observed in 3 patients (1.06%).
Additionally, one unit of erythrocyte suspension was kept ready in the OR for anticipated major bleeding. In four patients identified preoperatively as high-risk due to extensive adhesions or comorbidities on computed tomography (CT) scans, a cell-saver device was preoperatively set up.
ROTEM-based viscoelastic testing was used in 21 patients (7.44%) due to intraoperative bleeding difficulties. ROTEM® provided real-time assessment of hyperfibrinolysis, dilutional coagulopathy, fibrinogen levels, factor deficiencies, platelet function, and heparin/protamine balance, enabling appropriate blood product replacement. Among all patients, 198 (70.21%) required cryoprecipitate and 125 (44.32%) required fibrinogen replacement.
Pacemaker dependency was noted in 6 patients (2.12%) at the end of surgery. Phrenic nerve injury resulting in diaphragmatic paralysis occurred in 2 patients (0.70%). All complications unique to this patient population are summarized in Table 3.
A total of 158 patients (56.02%) underwent fast-track extubation in the operating room. The mean ICU length of stay was 17.18 ± 19.69 days. ECMO support was required in 25 patients (8.86%). Overall mortality was observed in 34 patients (12.05%).
Discussion
Redo cardiac surgery in pediatric patients presents significant anesthetic challenges due to increased surgical complexity, adhesions, altered mediastinal anatomy, heightened bleeding risk, and a greater susceptibility to arrhythmias. In our study, we retrospectively analyzed the anesthetic management of 282 pediatric patients who underwent redo cardiac surgery and identified key perioperative considerations and complications that necessitate meticulous preparation and a multidisciplinary approach.
One of the most critical aspects of redo sternotomy is the risk of vascular and cardiac injury during re-entry. Previous studies have reported an increased incidence of major vessel injuries, particularly in patients with extensive adhesions from prior surgeries [7,8]. In our series, major vascular injury involving the atrium, ventricle, pulmonary artery, or aorta occurred in 4 patients (1.4%). This rate is consistent with previously reported incidences ranging from 1% to 5% [9]. In three of these cases, emergency cardiopulmonary bypass (CPB) was initiated via femoral cannulation guided by pre-prepared reference sheets, underscoring the importance of having peripheral vascular access readily available in high-risk patients. Previous studies have demonstrated that femoral cannulation is a safe and effective strategy in pediatric reoperations where central cannulation poses a high risk [3,4].
Bleeding remains a major challenge in redo pediatric cardiac surgery, often necessitating intraoperative transfusion and hemostatic intervention. In our study, excessive bleeding requiring ROTEM (rotational thromboelastometry)-guided hemostatic therapy was observed in 21 patients (7.44%), highlighting the importance of point-of-care coagulation monitoring. Prior studies have shown that ROTEM can improve targeted transfusion strategies, minimize unnecessary blood product use, and help prevent dilutional coagulopathy [10-13]. Moreover, a significant proportion of patients required cryoprecipitate (70.2%) and fibrinogen replacement (44.3%), reinforcing the need for proactive blood management protocols.
Another important concern in redo cardiac surgery is the increased incidence of arrhythmias, which may require defibrillation or cardioversion. In our cohort, ventricular fibrillation requiring defibrillation occurred in 18 patients (6.38%), while supraventricular tachycardia necessitating cardioversion was observed in 3 patients (1.06%). These findings are consistent with existing literature suggesting that reoperations elevate the risk of intraoperative arrhythmias due to previous scarring and conduction system disturbances [14]. As implemented in our study, the routine placement of external defibrillation pads and continuous arrhythmia monitoring may be recommended for this patient population.
In recent years, fast-track extubation has been advocated in pediatric cardiac surgery cases, with several studies supporting its feasibility [15-18]. In our study, despite the complexity of the pathologies and the fact that the patients underwent redo surgery, the majority (56.02%) were extubated on the operating table. Notably, none of these patients required reintubation. The feasibility of fast-track extubation even in these complex redo cases is promising for increasing fast-track extubation rates in primary congenital heart surgeries as well.
Postoperative outcomes in our study revealed prolonged intensive care unit (ICU) stays (17.18 ± 19.69 days) and the need for extracorporeal membrane oxygenation (ECMO) in 25 patients (8.86%). In the study by Yin et al. [19], ICU stay duration was also reported to be longer in redo cardiac surgeries compared to initial surgeries. The overall mortality rate in our cohort was 12.05%, which is within the range reported in previous studies on complex congenital heart diseases requiring reoperation [20,21]. These findings highlight the need for optimized perioperative strategies to improve long-term outcomes in this vulnerable population.
Limitations
This study is limited by its retrospective, single-center design, which may restrict the generalizability of the findings to other institutions or populations. Additionally, the absence of a control group and potential confounding factors inherent in retrospective data collection may have influenced the observed outcomes.
Conclusion
Our study emphasizes the challenges of anesthetic management in pediatric redo cardiac surgery and highlights the importance of meticulous planning, intraoperative vigilance, and targeted hemostatic and arrhythmia management. Future prospective studies and multicenter collaborations are essential to further refine perioperative approaches and improve clinical outcomes in this high-risk group of patients.
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, and 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.
References
1. Mustafa MR, Neijenhuis RML, Furci B, Tsang VT. Neck cannulation for bypass in redo sternotomy in children and adults with congenital heart disease. Interact Cardiovasc Thorac Surg. 2020;31:108–12.
2. Bhende VV, Sharma TS, Krishnakumar M, et al. The myths, perils, and pitfalls of redo pediatric cardiac surgery: the new normal in developing countries such as India. Cureus. 2024;16(1):e52642.
3. Adibi A, Mohajer K, Plotnik A, et al. Role of CT and MRI prior to redo sternotomy in paediatric patients with congenital heart disease. Clin Radiol. 2014;69:574–80.
4. Kuralay E, Bolcal C, Cingoz F, et al. Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience. Ann Thorac Surg. 2004;77:977–81.
5. Brancaccio G, Perri G, Della Porta M, et al. Use of carotid artery cannulation during redo sternotomy in congenital cardiac surgery: a single-centre experience. Interact Cardiovasc Thorac Surg. 2021;33(1):119–23.
6. Temur B, Davutoglu A, Dogruoz A, et al. Utility of cervical cannulation during difficult resternotomy in congenital heart surgery. World J Pediatr Congenit Heart Surg. 2020;11:65–70.
7. Abou Zahr R, Gooty V, Tandon A, et al. Feasibility of real-time cine cardiac magnetic resonance imaging to predict the presence of significant retrosternal adhesions prior to redo sternotomy. J Cardiovasc Magn Reson. 2019;21(1):67.
8. Park CB, Suri RM, Burkhart HM, et al. Identifying patients at particular risk of injury during repeat sternotomy: analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg. 2010;140(5):1028–35.
9. Kirshbom PM, Myung RJ, Simsic JM, et al. One thousand repeat sternotomies for congenital cardiac surgery: risk factors for reentry injury. Ann Thorac Surg. 2009;88(1):158–61.
10. Naguib AN, Carrillo SA, Corridore M, et al. A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery. J Extra Corpor Technol. 2023;55(2):60–9.
11. Scott JP, Niebler RA, Stuth EAE, et al. Rotational thromboelastometry rapidly predicts thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass. World J Pediatr Congenit Heart Surg. 2018;9(4):424–33.
12. Romlin BS, Wahlander H, Berggren H, et al. Intraoperative thromboelastometry with ROTEM analysis in pediatric cardiac surgery: a prospective observational study. Anesth Analg. 2011;112(1):30–6.
13. Nakayama Y, Nakajima Y, Tanaka KA, et al. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after pediatric cardiac surgery. Br J Anaesth. 2015;114(1):91–102.
14. Abouelella RS, Habib EA, AlHalees ZY, et al. Outcome of cardiac surgery in adults with congenital heart disease: a single center experience. J Saudi Heart Assoc. 2019;31(3):145–50.
15. Vakamudi M, Ramachandran TR, Kalyanaraman M. Recent advances in paediatric cardiac anaesthesia. Indian J Anaesth. 2012;56(6):491–500.
16. Kolovos NS, Gazit AZ. Early extubation following congenital heart surgery: time to move on. Pediatr Crit Care Med. 2022;23(7):566–7.
17. Kaushik J, Vijayakumar R, Soundaravalli B, et al. One-year experience after adoption of an on-table extubation protocol following pediatric cardiac surgery. Ann Card Anaesth. 2022;25(4):422–8.
18. Özalp Ş, Özcanoğlu HD, Öztürk E, et al. Assessment of the factors that affect fast-track or early extubation following pediatric cardiac surgery. Turk Gogus Kalp Damar Cerrahisi Derg. 2023;31(1):1–7.
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Serife Ozalp, Funda Gumuş Ozcan. Anesthetic management in pediatric cardiac reoperations: Experiences from our institution. Ann Clin Anal Med 2025;16(Suppl 3):S167-171
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Levofloxacin as a potential substitute for Trimethoprim-Sulfamethoxazole in Stenotrophomonas maltophilia infections: A retrospective cohort study
Onur Ozalp 1, Yusuf Yigit 1, Beyza Oncel 2, Ramazan Korkusuz 1
1 Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Basaksehir Cam and Sakura Hospital, Istanbul, Turkey, 2 Department of Pediatric Cardiology, University of Health Sciences Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22890 Received: 2025-09-11 Accepted: 2025-10-13 Published Online: 2025-10-22 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S172-176
Corresponding Author: Onur Ozalp, Department of Infectious Diseases and Clinical Microbiology, University of Health Sciences, Basaksehir Cam and Sakura Hospital, Istanbul, Turkey. E-mail: onur.ozalp@yahoo.com P: +90 212 909 60 00 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4284-2225
Other Authors ORCID ID: Yusuf Yigit, https://orcid.org/0009-0006-6681-1000 . Beyza Oncel, https://orcid.org/0000-0002-2857-8635 . Ramazan Korkusuz, https://orcid.org/0000-0002-9988-9596
This study was approved by the Ethics Committee of Basaksehir Cam and Sakura City Hospital (Date: 2023-11-22, No: 619)
Aim: Stenotrophomonas maltophilia (SM) is an opportunistic pathogen that commonly causes severe infections in individuals with weakened immune systems and is resistant to multiple drugs. Although TMP-SMX is the standard treatment, the emergence of resistance and adverse effects necessitates the investigation of alternative therapeutic approaches. Levofloxacin may serve as a viable alternative. The goal of this study is to compare the therapeutic benefits and risks of TMP-SMX and levofloxacin for the treatment of SM infections.
Materials and Methods: A retrospective cohort study was carried out in a tertiary care hospital between August 2020 and June 2023. The study included 54 adult patients diagnosed with SM infections, treated with either TMP-SMX or levofloxacin. The study compared clinical and microbiological outcomes, 30-day mortality, and hospital stay between the groups.
Results: Out of 54 patients, 41 (75.93%) were administered levofloxacin, with the remaining 13 (24.07%) treated with TMP-SMX. The overall recovery rate was 87.04%, with levofloxacin (87.80%) and TMP-SMX (84.62%) showing comparable outcomes (p=>0.999). There was no difference in 30-day mortality rates (5.00% versus 7.69%, p>0.999).
Discussion: Levofloxacin and TMP-SMX are equally effective for SM infections, achieving similar clinical results. The results indicate that levofloxacin is a promising option, particularly in environments with growing resistance to TMP-SMX. To ensure these findings are reliable, further studies are necessary with a more diverse patient population.
Keywords: levofloxacin, stenotrophomonas maltophilia, trimethoprim-sulfamethoxazole
Introduction
As an opportunistic pathogen, Stenotrophomonas maltophilia (SM), a non-fermentative Gram-negative bacillus, is increasingly recognized as a threat, particularly in healthcare settings. This organism often infects immunocompromised individuals, those with malignancies, cystic fibrosis, or those subjected to prolonged mechanical ventilation or invasive medical devices [1]. Although historically seen as having low virulence, SM’s multidrug resistance (MDR) has elevated its clinical significance, making it one of the toughest pathogens to combat in contemporary infectious disease management [1]. SM infections are on the rise worldwide, contributing significantly to hospital-acquired pneumonia, bloodstream infections, and urinary tract infections [2-4]. The mortality rate of SM bacteremia is alarmingly high, ranging between 14% and 69%, emphasizing the urgent requirement for effective therapeutic options [3,5,6].
Trimethoprim-sulfamethoxazole (TMP-SMX) has served as a key treatment for SM infections for decades [1,3,7]. Its past effectiveness and impressive in vitro results have established it as the leading treatment for most invasive SM infections. Despite its benefits, TMP-SMX is not without limitations. Adverse effects like kidney problems, allergic reactions, and bone marrow suppression, together with growing drug resistance, have led to the search for new treatments [3,5,7]. Concerns about the reliability of TMP-SMX as a first-line treatment have been raised because of its resistance rate, which has been reported as high as 30% in recent surveillance studies [1,5]. In situations where TMP-SMX resistance is present or administration is not feasible because of severe allergies or other clinical factors, quinolones are frequently employed as an alternative therapeutic strategy [5,6]. Levofloxacin, a broad-spectrum fluoroquinolone, is a possible replacement for TMP-SMX in treating SM infections [5-8]. A meta-analysis by Ko et al. Levofloxacin [6], including 663 individuals, found no significant difference between the TMP-SMX and levofloxacin groups. Levofloxacin’s mechanism of action differs from TMP-SMX, targeting bacterial DNA gyrase and topoisomerase IV [1]. Studies conducted in laboratory settings indicate that levofloxacin is highly effective against various pathogens, and its pharmacokinetic and pharmacodynamic profile make it a promising treatment choice for respiratory and bloodstream infections [4,5,8].
Despite their widespread use, a lack of comparative studies limits our understanding of the effectiveness and safety of TMP-SMX and levofloxacin in clinical settings [2,5]. This research focuses on comparing real-world data for TMP-SMX and levofloxacin, highlighting the effectiveness of levofloxacin as a viable alternative treatment.
Materials and Methods
This single-center, retrospective cohort analysis was performed in the infectious diseases inpatient clinic of Basaksehir Cam and Sakura City Hospital, a tertiary care teaching hospital, between August 2020 and June 2024. This research was conducted in accordance with the Declaration of Helsinki and granted ethical clearance by the institutional review board (IRB No: 22.11.2023.619).
The hospital’s microbiology database served as the source for identifying patients. The inclusion criteria were being older than 18 years old, having a positive culture for SM from a clinically significant sterile or non-sterile site (e.g., blood, respiratory secretions, urine, or wound), and receipt of either TMP-SMX or levofloxacin as monotherapy for at least 48 hours. Exclusion criteria included the following: patients who were admitted to the intensive care unit (ICU), those with concomitant infections and/or receiving antibiotic therapy for other reasons, patients with colonization, individuals receiving combination therapy, and patients with incomplete data. (Figure 1)
Data collected included demographic factors (age, sex, health conditions (diabetes, kidney disease, cancer, organ transplant), infection details (location, source, culture), and use of medical devices (catheters, ventilators). All SM isolates were tested in the hospital’s microbiology laboratory. The antibiotic susceptibility testing for TMP-SMX was performed using the disk diffusion method, and the test results were evaluated according to EUCAST criteria (EUCAST v.14). Since TMP-SMX resistance is rare, isolates found to be resistant by the disk diffusion method were retested using an automated antibiotic susceptibility testing device (Phoenix, BD). The MIC range for TMP-SMX in this device is 2–8 µg/mL. As there are no clinical breakpoint values in EUCAST, but levofloxacin has clinical relevance, its antibiotic susceptibility testing was performed using the disk diffusion method, and the results were evaluated according to CLSI criteria (CLSI M100 31st Edition).
Quality control was achieved by adding reference strains (e.g., Escherichia coli ATCC 25922) to all batches of susceptibility tests. Discrepancies in vitro susceptibility and clinical results were recorded for analysis. Participants’ Charlson Comorbidity Index scores were calculated. The daily dosage of TMP-SMX ranged from 8 to 12 milligrams (mg) per kilogram (kg), whereas levofloxacin had a daily dose of 750 mg. Route of administration (intravenous [IV] or oral [PO]) and duration of antibiotic therapy data were gathered.
The main goal of treatment is symptom resolution within 30 days without increasing or changing antibiotic therapy. The secondary endpoints of the study included microbiological eradication (negative follow-up cultures within 7 days of completing therapy), 30-day All-Cause Mortality, and Length of Hospital Stay. Given the relatively small sample size (n=54) and the imbalance between treatment groups (41 levofloxacin vs. 13 TMP-SMX), the statistical power of our analysis was limited, and this is acknowledged as a methodological constraint.
Statistical Analysis
Data manipulation, visualization, and reporting were carried out using various R packages in version 4.3.3 for statistical analysis. Reusable object-oriented structures were built with the R6 package, resulting in greater flexibility and modularity for statistical workflows.
Descriptive statistics were computed for all variables to provide a comprehensive overview of the sample. To check for normal distribution, the Shapiro-Wilk test was applied to the numerical data. The mean and standard deviation (SD) were used to summarise parametric data. Median (minimum-maximum) intervals provided a summary of the nonparametric data. A summary of categorical data was presented with n (number of observations) and percentage frequency.
Relationships and differences between groups were analyzed using inferential statistics to conclude. Tests were chosen to consider the normality of the numerical data (determined via the Shapiro-Wilk test) and their compatibility with the test’s prerequisites. For normally distributed numerical data, the t-test is suitable for comparing two independent groups, whereas ANOVA facilitates comparisons across multiple groups. In cases of non-normal data distribution, the Wilcoxon rank-sum test was employed for two-group comparisons, and the Kruskal-Wallis test was used for comparisons involving over two groups. Chi-squared tests were employed for analysis of categorical data with larger samples (minimum five observations per cell), while Fisher’s exact test was used for smaller samples. Any P value above 0.050 was considered significant.
Ethical Approval
This study was approved by the Ethics Committee of Turkiye Basaksehir Cam and Sakura City Hospital (Date: 2023-11-22, No: 619).
Results
Fifty-four patients participated in the study. A median age of 63 years (range: 21–88 years) was observed among participants, 27.78% (n = 15) of whom were female. Cardiovascular disease (35.19%), neurological disease (27.78%), diabetes mellitus (24.07%), and pulmonary disease (22.22%) were the most frequent comorbidities. Solid malignancies were observed in 27.78% of study participants, hematologic malignancies in 7.41%, and chronic kidney disease in 24.07%. The median score for the Charlson Comorbidity Index was 4 (0-11). A summary of the participants’ demographic and clinical profiles is provided in Table 1. The most common infection sites were the urinary tract (40.74%), pneumonia (37.04%), soft tissue (11.11%), and bacteremia (9.26%). Intravenous antibiotics were administered to the majority of patients (83.33%), while oral antibiotics were given to the remaining 16.67%. Antibiotic usage was dominated by levofloxacin (75.93%, n=41), while trimethoprim-sulfamethoxazole (TMP-SMX) was the second most used at 24.07% (n=13). The mean treatment duration was 11.28 ± 4.34 days.
Sensitivity rates for all patients were 94.44% for TMP-SMX and 90.74% for levofloxacin. The study showed a recovery rate of 87.04% among patients, and a 30-day mortality rate of 5.56% (n=3) (Table 1).
The comparative data for patients given TMP-SMX and levofloxacin are presented in Table 2. Patients receiving levofloxacin (n=41) and TMP-SMX (n=13) were similar in baseline characteristics, including age, sex, and comorbidities like cardiovascular, neurological, and pulmonary disease. Participants receiving levofloxacin showed a significantly higher sensitivity (100%) to levofloxacin (p<0.001). When compared to TMP-SMX, levofloxacin showed equal effectiveness in treating SM (87.80%, n=36 vs. 84.62%, n=11). Both groups showed similar 30-day mortality rates (5.00% vs. 7.69%), as seen in Table 2.
Discussion
We discovered that levofloxacin and TMP-SMX showed similar clinical outcomes in our cohort, resulting in comparable recovery and mortality rates. However, due to the small sample size and wide confidence intervals, these findings cannot establish equivalence, and the results should be interpreted with caution. Moreover, the retrospective and single-center design of this study introduces potential selection bias and restricts the generalizability of our findings. Therefore, the observed similarity between TMP-SMX and levofloxacin should not be considered conclusive but rather hypothesis-generating.
The sensitivity differences observed highlight levofloxacin’s potential benefits, particularly in environments with rising TMP-SMX resistance. The resistance rate for TMP-SMX was lower in our study at 5.56% compared to the 20.3% reported in a study from our country [1]. In line with our research, that study [1] observed a levofloxacin resistance rate of only 7.6%. The presence of intensive care unit patients in Cıkman et al.’s study might explain the variation in resistance values for TMP-SMX [1]. Prior antibiotic use might be linked to an increased risk of infection, with resistant strains in intensive care unit patients.
Mortality rates for SM bacteremia, ranging from 14% to 69%, emphasize the critical need for effective treatment strategies [4-11]. The mortality rate in our study (5.5%) was lower than in the literature. Mortality rate variation is influenced by multiple factors, such as participant age, status (inpatient or ICU), and primary diagnosis (e.g., cystic fibrosis, malignancies) [1,4,5,7]. Even though the groups responded differently to antibiotics, their clinical outcomes were comparable. Recovery rates were similar in both groups, with 87.80% in the levofloxacin group and 84.62% in the TMP-SMX group, revealing no statistically significant difference. In both groups, 30-day mortality was low and comparable (5.00% for levofloxacin, 7.69% for TMP-SMX). A study revealed that the mortality rate of SM was 27.5% in the TMP-SMX treatment group and 20% in the levofloxacin treatment group [7]. Earlier systematic reviews have confirmed this finding, indicating that fluoroquinolones, such as levofloxacin, exhibit increased effectiveness against SM and may decrease mortality when employed as first-line treatment [2,6,7]. The current study, along with other studies [1,4,6,7,12,13], suggests that both antibiotics can be effective in treating SM infections if they prove sensitivity to the infection in vitro.
The favorable PK/PD properties of levofloxacin lead to its efficacy in treating SM infections. Its high concentration in respiratory secretions and tissues makes it effective for pulmonary infections, a common site of SM colonization and infection [1,5,9,14]. Our study shows that pulmonary infections are a frequent site of SM, and levofloxacin appears to be as successful as TMP-SMX in treating these infections and achieving survival. Notably, Monte Carlo simulations and PK/PD models suggest that fluoroquinolones, like levofloxacin, are better at achieving optimal target concentrations compared to TMP-SMX [1,3,15]. These findings back up their use as the favored choice in severe cases or when TMP-SMX is not an option.
Limitations
The small sample size and the single-center nature of the study may restrict the generalizability of the results. In addition, retrospective medical records at our institution did not consistently capture detailed adverse event data (e.g., nephrotoxicity, cytopenia, QT prolongation); therefore, safety outcomes could not be systematically assessed, which constitutes another important limitation. Furthermore, the retrospective design of the analysis may introduce selection bias, underscoring the need for prospective randomized controlled trials to confirm the efficacy of levofloxacin in larger and more diverse populations.
Conclusion
Our study highlights levofloxacin as a workable treatment option for SM infections, demonstrating similar clinical outcomes to TMP-SMX in our limited cohort, with improved antimicrobial sensitivity. However, these findings should be interpreted with caution and require confirmation in larger, prospective, multicenter studies. These findings point to levofloxacin as a possible treatment for SM infections, particularly in environments where resistance to TMP-SMX is a major issue. Future research should confirm these findings in larger groups and examine the long-term effects of levofloxacin on drug resistance and patient health.
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, and 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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6. Ko JH, Kang CI, Cornejo-Juarez P, et al.Fluoroquinolones versus trimethoprim-sulfamethoxazole for the treatment of Stenotrophomonas maltophilia infections: a systematic review and meta-analysis. Clin Microbiol Infect. 2019;25(5):546-54.
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Onur Ozalp, Yusuf Yigit, Beyza Oncel, Ramazan Korkusuz. Levofloxacin as a potential substitute for Trimethoprim-Sulfamethoxazole in Stenotrophomonas maltophilia infections: A retrospective cohort study. Ann Clin Anal Med 2025;16(Suppl 3):S172-176
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Economic burden of falls in hip fracture patients: A comprehensive cost analysis from emergency admission to total fall-related expenditures
Bünyamin Arı, Sabit Numan Kuyubaşı
Department of Orthopedics and Traumatology, Faculty of Medicine, Kütahya Health Sciences University, Kütahya, Türkiye
DOI: 10.4328/ACAM.22894 Received: 2025-09-11 Accepted: 2025-10-13 Published Online: 2025-10-23 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S177-181
Corresponding Author: Bünyamin Arı, Department of Orthopedics and Traumatology, Faculty of Medicine, Kütahya Health Sciences University, Kütahya, Türkiye. E-mail: bunyamin.ari@ksbu.edu.tr P: +90 506 264 13 85 Corresponding Author ORCID ID: https://orcid.org/0000-0001-7638-7932
Other Authors ORCID ID: Sabit Numan Kuyubaşi, https://orcid.org/0000-0002-3021-0581
This study was approved by the Ethics Committee of Kütahya Health Sciences University, Non-Interventional Clinical Research (Date: 2021-05-26, No: 2021/09-11)
Aim: This research was conducted to measure the total economic burden of fall-related hip fractures, including all medical costs in the case of emergency hospitalisation and the overall costs of falls in the older adult population.
Materials and Methods: The observational study analysed 113 patients with a hip fracture caused by a fall retrospectively. The structured three-part information form was used to gather detailed demographic, clinical, and cost data. When the direct cost data were missing, reimbursement rates were standardised, and SGK reimbursement rates and rates based upon publications were applied to supplement the analysis. Multivariate regression and sensitivity analysis were used to determine the leading factors of rising healthcare expenses.
Results: The studied population was 78.5 years old, and 60 per cent of the sample was female. The overall cost driver was inpatient care, constituting 90 per cent of the total costs, with an average total cost of about 9780 units of the local currency. Old age, the occurrence of chronic comorbidities, and admissions to ICUs were significant factors that significantly increased costs, indicating the multidimensional relationship between clinical severity and economic costs.
Discussion: Hip fractures due to falls in the elderly pose a substantial financial burden on the healthcare system, which has been mainly attributed to the high costs of inpatient care involving surgical procedures, anaesthesia administration, and intensive care. These results accentuate the need for targeted prevention strategies and cost-efficient management plans to reduce clinical and financial effects, especially in a high-risk population.
Keywords: hip fracture, falls, economic burden, cost analysis, inpatient care
Introduction
Among the elderly, falls—especially hip fractures—are an increasingly complex public health problem, endangering patients’ lives and well-being while creating a major financial burden on healthcare systems worldwide [1]. The cumulative and progressive nature of costs begins with the patient’s arrival in the emergency department, where outpatient care rapidly shifts to emergency and inpatient services [2]. This cycle includes acute care, surgery, extended hospital stays, ambulance transfers, ICU admissions, and rehabilitation, all of which collectively amplify the overall financial toll [3].
We will utilize a comprehensive patient information system to gather detailed socio-demographic data (age, gender, marital status, education level, BMI) and clinical characteristics (chronic diseases, medication use, sensory impairments, prior falls). These data will allow us to construct a model capturing both direct medical expenditures and indirect costs associated with hip-fracture-related falls [4]. Direct costs, such as emergency and inpatient care, represent only part of the economic burden, as long-term rehabilitation, surgical interventions, anaesthesia, and specialized treatments require significant and ongoing financial resources [5]. Potential sequelae—including infections, partial disability, and the need for corrective surgeries—add further complexity to cost distribution.
Our analysis integrates these financial layers to reflect real-world clinical and fiscal conditions faced by health economists, policymakers, and practitioners. By addressing heterogeneity, missing data, and variability through reimbursement paradigms and literature-based evidence, our estimates aim to be inclusive and representative of current healthcare realities [6,7]. This combined approach will help identify the primary cost drivers and intervention opportunities, providing a clearer understanding of the economic burden and guiding resource allocation strategies [8].
Ultimately, we aim to present a comprehensive, integrative model that captures the full continuum of expenses—from emergency response through long-term follow-up—offering valuable insights for clinicians and policymakers. These findings will inform preventive strategies, support efficient resource management, and contribute to building more sustainable healthcare systems in the context of a rapidly aging population [9].
Materials and Methods
Study Design and Population
The study was a retrospective, observational study in which researchers sought to measure the overall economic impact of falls that cause major hip fractures. The patients with hip fractures who were admitted to our facility after a fall were the population of the study. The hospital records were used to identify those cases, and only complete cases in terms of clinical and cost information were added. It excludes the analysis of patients who had a non-fall as the cause of hip fracture or had a lot of missing data.
Data Collection and Patient Information
Patient data were collected using a three-part form designed for this study:
Socio-Demographic Data: Age, gender, marital status, education level, BMI, presence of chronic illnesses, current medications, and sensory impairments.
Fall-Related Clinical Information: Time and circumstances of the fall, clinical diagnosis, ICD-10-AM code, ED outcome, hospital stay details (including ICU stay), and therapies administered.
Cost Data: Detailed expenses from the ED (diagnostics, labs, radiology, drugs, urgent interventions), inpatient care (surgery, anaesthesia, ICU, rehabilitation), and other services (ambulance, post-discharge care).
Cost Estimation
When direct cost data were missing, SGK (Sosyal Güvenlik Kurumu) reimbursement rates were used to complete the dataset, and peer-reviewed literature values were incorporated to strengthen consistency with real-world clinical and financial practice. This approach enabled inclusion of both direct medical expenses and indirect costs, such as long-term management and complication-related expenditures, ensuring a comprehensive estimate of total economic burden.
Statistical Analysis
Statistical analysis performed on the data was based on more complex statistical techniques designed for the World Health Organisation economic evaluation. There were descriptive statistics to summarise the characteristics of patients and the elements of the cost. Statistical inference methods such as multivariate regression equations were employed in analysing the connection between the patient-related factors (like demographic data, comorbidities, and severity of injury) and total spending. Sensitivity analyses were also conducted to gauge how our cost estimates vary widely within alternative reimbursement scenarios. A statistical significance was set below p < 0.05, and all the analyses were carried out through routine statistical software.
Ethical Approval
This study was approved by the Ethics Committee of Kütahya Health Sciences University, Non-Interventional Clinical Research Ethics Committee (Date: 2021-05-26, No: 2021/09-11).
Results
This study of 113 patients with fall-related hip fractures revealed key demographic, clinical, and economic trends. The mean age was 78.5 years, with females comprising 60% of the cohort. Socioeconomic factors such as marital status and education influenced outcomes. High rates of chronic illnesses (hypertension, diabetes, cardiovascular disease) and sensory impairments increased clinical complexity and management difficulty.
Temporal fall patterns, ICD-10-AM codes, and the high rate of hospital and ICU admissions highlighted the acute clinical impact of these injuries. Economic analysis showed that inpatient care, particularly surgery, anaesthesia, and ICU treatment, represented the major cost drivers. Cost comparisons across age groups and multivariate regression confirmed that advanced age, comorbidities, and ICU admissions significantly increased total expenditures.
Overall, these findings emphasize the need for targeted prevention programs and cost-effective treatment strategies to reduce the clinical and economic burden of hip fractures in elderly patients.
The statistics show that cohort hypertension is 62 per cent, diabetes mellitus is 35 per cent, and cardiovascular diseases are 27 per cent, highlighting a severe disease burden posing potential impaired recovery and treatment after hip fracture. What makes it more complicated is that almost 50% (49%) of the patients are under chronic medication, and 53% of them have sensory impairments, factors that may prolong the hospital stay and even incur more costs. These comorbidities not only increase the total clinical risk expression but also significantly impact the cost analysis since patients with several comorbidities will tend to take more intensive and prolonged care and thus increase the total expenditures related to the injuries brought about by the falls.
The chart shows that 40% of patients were male and 60% female, consistent with the demographic data and reflecting the higher postmenopausal osteoporosis risk in women. This suggests that prevention and treatment strategies may need to be tailored, particularly for elderly females who appear more susceptible.
Falls occurred throughout the day (27% morning, 44% afternoon, 29% evening) with a slight afternoon peak. Pertrochanteric fractures (S72.0) were most common (53%), followed by femoral neck fractures (35%). Hospitalization was frequent (75%), with a mean stay of 7.5 days, and 18% required ICU care, underscoring the severity of these injuries. Marital status influenced recovery: single patients may face greater challenges in self-care, potentially prolonging hospital stay and increasing costs.
Emergency department costs averaged 580 LC, with radiology representing the largest share (mean 200 LC), highlighting its importance in acute fracture evaluation. Laboratory tests and drug costs were lower and showed minimal variation, suggesting standardized ED protocols.
Inpatient care represented the largest share of total costs. Surgery was the most expensive component (mean 4,000 LC; range 2,500–6,000 LC), followed by anaesthesia and operating room fees (1,500 LC). ICU care added a significant expense (mean 2,500 LC), highlighting the need for strategies to prevent complications that require intensive care. The variability of these costs reflects differences in case severity and resource use.
Figure 1 shows that pertrochanteric fractures (S72.0) were most common (53%), followed by femoral neck fractures (S72.1, 35%) and other codes (12%). This distribution underlines the clinical and economic significance of pertrochanteric fractures and the need for tailored diagnostic and treatment strategies for this subgroup. The average total cost of the patients under the age of 65 years is 8000 LC, and those aged between 65-74, 75-84, and 85 years and more are 9500 LC, 10500 LC, and 11000 LC, respectively. Since these differences are statistically significant at (p < 0.05), they are not just a result of random chance, but rather an actual association of age and cost. Such a tendency can be explained by the fact that older patients are more exposed to comorbidity and complications, which results in a need to stay longer in hospitals and receive more intensive care. The age-stratified cost analysis justifies the importance of age-related preventive and management strategies to reduce the financial impact on the oldest parts of the population. Figure 2 is a bar chart that compares the mean total cost of fall-based treatment among various age groups (American Association of Family Physicians, 2016a). As the chart shows, it can be identified that the costs become higher with each age, and the mean cost is the highest among patients over 85 (11,000 LC) and the lowest among patients younger than 65 (8,000 LC). That gradient highlights the increasing care resource utilisation and risk of complications among older patients, which could be explained by the emerging comorbidity burden and increased frailty. The graphical pattern complements the belief that age is an important factor that affects the cost of treatment and justification of taking age-specific healthcare planning and preventive measures to reduce the economic effects of hip fractures in older people. The presence of chronic diseases (beta = 200 LC, absolute t value = 4.4), age (beta = 50 LC per year, t = 2), and ICU (beta = 1500 LC, t = 20) figures as some statistically significant determinants of the regression model. Whereas the body mass index (BMI) has a positive relation (beta = 20 LC), its impact was not significant (p = 0.10). The model also exhibits other factors carrying an impact (beta = 100 LC, p = 0.05). These results enable drawing the following conclusions: advanced age, chronic illnesses, and the necessity of intensive treatment are the most critical factors influencing the rising healthcare costs among the population of this patient group. The regression serves fruitful data on which aspects of patients are more sensitive in pointing towards increased spending that can be used in shaping specific cost-controlling interventions.
Sensitivity analysis comparing SGK reimbursement rates with literature-based estimates showed minimal differences (−3.4% for ED costs, −2.2% for inpatient costs), supporting the robustness and validity of the cost analysis.
Discussion
The current study aims to give an in-depth overall analysis of the economic impact of fall-related hip fracture preventability in elderly patients by combining highly specific demographic, clinical, and cost factors of 113 patients. We established that the mean age of the patients was 78.5 years, with a marked preponderance of the female gender, who formed 60.0 per cent of the cohort. This fact highlights the reported vulnerability of older women to osteoporosis and subsequent fragility fractures [10]. This inequality between genders, combined with the prevalence of chronic conditions like hypertension, diabetes mellitus, cardiovascular diseases, among others, creates an image of a population with multifaceted health-related factors that make it susceptible to falls as well as worse outcomes after traumatic injury. The complex nature of the health status of these patients, involving the high frequency of sensory impairments and chronic medication use, further complicates the clinical management process and demands a more resource-consuming approach to treatment, reflected in a high frequency of hospitalisation and a significant number of patients needing intensive care [11]. Combined with the burden of chronic diseases and the increased need of this patient population in higher care, the multifactorial relationship of old age and the need of higher care also addresses the clinical dilemma of older patients with more frequent and devastating challenges due to the financial costs of higher care directly translated to expenditures on care of the particular patient population, which has been corroborated with the study focusing on economical aspect of osteoporotic fractures as well [12].
The examination of cost aspects showed that the most significant part of the overall financial liability is inpatient care, with surgical procedures, anaesthesia, and costs in the intensive care unit as the biggest categories of expenses. The statistics show that the average expenditure incurred by patients was about 9780 units of the local currency, and the inpatient care expenses contributed to 90 per cent of the amount. Notably, on stratified analysis of costs across age groups, there was a statistically significant trend of a greater cost increase with age, with the elderly groups of 85 years and above showing the highest mean total costs of 11,000 local currency units against 8,000 local currency units among those aged below 65 years [13]. The age-related cost increase can be explained by a few aspects, such as the higher probability of pre-existing comorbidities, the increased risk of complications, the following protracted hospitalisation, and intensive care support. These observations were further confirmed through the multivariate regression analysis that found the existence of advanced age, the burden of chronic illness, and ICU admission as influential in predicting the rise in expenditures. Specifically, the differences due to ICU admission were extreme with the mean total costs being much larger in ICU patients compared to non-ICU patients- so not only the importance of intensive care in the treatment of severe cases comes out clearly but one can also calculate the addition of potential cost savings by putting in place specific measures to prevent the development of complications [14]. These data bear significant implications for clinical practice and healthcare policy. The apparent financial burden created by the hip fracture caused by falls and most likely experienced by the most vulnerable segment of the elderly population warrants a reconsideration of the existing preventive methods and resource distribution. Such proactive interventions as fall prevention programs, early detection of high-risk patients, and introduction of specific interventions to treat chronic diseases, offset the fall risk and curtail the utilisation of expensive acute care services [15]. Further, the combination of standardised data on reimbursement with traditionally estimated locations of cost in our study gives credence to the strength of our results and the potential present to enable cost-effective management guidelines. Although the retrospective nature of the study and the fact that it is based on hospital records introduce some limitations, such as the possibility of data gaps or the fact that it required the use of a less consistent clinical practice, the comparability of our empirical data with the fixed benchmarks adds credibility to the conclusions we made. In future studies, attempts should be made to include future data collection and a wider variety of clinical conditions to test the validity of these results further and examine the economic implications of hip fractures in the long term [16]. Considering the workforce-related ageing of the world population, our analysis highlights the necessity of building long-term plans of health systems that would make patient outcomes more favourable and ease the economic costs of the injuries following falls [17].
Limitations
This study was retrospective and relied on hospital records, which may contain missing or incomplete data and limit generalizability. Additionally, indirect costs and outpatient follow-up expenses might not have been fully captured, potentially leading to an underestimation of the total economic burden. Moreover, the cost calculations were based on SGK reimbursement rates, which have not been regularly updated despite currency fluctuations and inflation, potentially resulting in relatively lower cost estimates compared to real-world expenditures.
Conclusion
This study shows that treating fall-related hip fractures in the elderly carries a high cost, mainly due to inpatient care, surgery, anaesthesia, and ICU treatment. In 113 patients, advanced age, multiple comorbidities, and ICU need were the main cost drivers. With a mean age of 78.5 years and a female predominance, the findings highlight the urgency of fall-prevention strategies and efficient resource allocation to reduce both incidence and economic burden in the context of a globally ageing population.
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, and 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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Download attachments: 10.4328.ACAM.22894
Bünyamin Arı, Sabit Numan Kuyubaşı. Economic burden of falls in hip fracture patients: A comprehensive cost analysis from emergency admission to total fall-related expenditures. Ann Clin Anal Med 2025;16(Suppl 3):S177-181
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Comparison of transvaginal ultrasonography, office hysteroscopy, and operative hysteroscopy results in patients with detected endometrial pathology
Elif Uçar 1, Melih Bestel 1, Bülent Babaoğlu 2, Süleyman Salman 3
1 Department of Midwifery, Faculty of Health Sciences, Istanbul Esenyurt University, Istanbul, Turkey, 2 Department of Obstetrics and Gynecology, Batman Training and Research Hospital, Batman, Turkey, 3 Department of Obstetrics and Gynecology, Health Sciences University, Gaziosmanpasa Training and Research Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22904 Received: 2025-09-18 Accepted: 2025-10-20 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S182-187
Corresponding Author: Elif Ucar, Department of Obstetrics and Gynecology, Istanbul Esenyurt University, Private Esencan Hospital, Istanbul, Turkey. E-mail: eliflyy@hotmail.com Corresponding Author ORCID ID: https://orcid.org/0000-0001-5302-4688
Other Authors ORCID ID: Melih Bestel, https://orcid.org/0000-0001-6677-2087 . Bülent Babaoğlu, https://orcid.org/0000-0002-1255-7071 . Süleyman Salman, https://orcid.org/0000-0001-7090-6105
This study was approved by the Ethics Committee of Taksim Training and Research Hospital (Date: 2019-01-30, No: 18)
Aim: This study aims to compare the diagnostic accuracy of transvaginal ultrasonography (TVUSG), office hysteroscopy (HSK), and operative hysteroscopy
(HSK) in patients with endometrial pathology and to evaluate their superiority in terms of effectiveness and reliability.
Materials and Methods: The data of 912 female patients who were referred to the gynecology outpatient clinic of the Department of Obstetrics and Gynecology between January 2012 and July 2019 and who were diagnosed with endometrial pathology during examination were retrospectively reviewed. The patients
included in the study underwent pelvic examination, transvaginal ultrasonography, and diagnostic hysteroscopy, respectively, and the pathological results were
compared with the preliminary diagnoses.
Results: The mean age was 44.72±9.77. Ultrasonography revealed 60% polyps, 10.7% fibroids, 12.7% normal findings, and 16.6% other pathologies. Office
HSK detected 53.7% polyps, 5.3% fibroids, 29.6% normal findings, and 11.2% other pathologies; operative HSK detected 71% polyps, 12.4% fibroids, 8.2%
normal findings, and 7.4% other pathologies. The overall sensitivity of TVUSG was 91.2%, specificity 23.4%; the sensitivity of office HSK was 74.2%, specificity
38.5%; the sensitivity of operative HSK was 95.1%, specificity 29.6%.
Discussion: Transvaginal ultrasonography, hysteroscopy, and operative hysteroscopy have high accuracy rates in detecting endometrial pathologies. Operative
hysteroscopy has the highest diagnostic value in detecting endometrial pathologies. However, all three methods have different advantages and are recommended
to be used in conjunction with each other in patient treatment planning.
Keywords: endometrial pathology, transvaginal ultrasonography, office hysteroscopy, operative hysteroscopy, fibroid, polyp, hyperplasia
Introduction
Endometrial biopsy is one of the fundamental diagnostic methods frequently used in gynecology for the diagnosis and management of conditions such as abnormal uterine bleeding, endometrial hyperplasia, and endometrial polyps. This method allows for pathological examination by obtaining tissue samples from the uterine cavity and plays a critical role in the clinical decision-making process [1].
Abnormal uterine bleeding is usually a sign of reproductive system pathologies, but it can rarely be an indicator of disorders in other systems [2]. Clinically, this condition can be associated with polyps and fibroids in 20% of cases during adolescence; it has been associated with pathologies such as polyps, fibroids, hyperplasia, or endometrial cancer in 30% of cases during the reproductive period and in 50% of cases during the peri-postmenopausal period [3,4].
In recent years, with the advancement of imaging technologies, different methods have become widespread in the evaluation of endometrial pathologies. These methods include transvaginal ultrasonography (TVUSG), hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy (HSK), and magnetic resonance imaging (MRI). Transvaginal ultrasonography, in particular, stands out as a fast and non-invasive method with a high accuracy rate in the evaluation of uterine pathologies [5]. HSK has become an important option for both diagnosis and treatment due to its minimally invasive nature and applicability in outpatient settings [6].
This study aims to compare the diagnostic accuracy of TVUSG, Office HSK, and operative HSK in patients with endometrial pathology and to evaluate the superiority of these methods in terms of effectiveness and reliability.
Materials and Methods
January 2012-July 2019, the data of 1,998 female patients who visited the gynecology outpatient clinic of the Department of Obstetrics and Gynecology at a tertiary education and research hospital, were diagnosed with endometrial pathology during examination, and underwent office and/or operative hysteroscopy procedures, were retrospectively reviewed and recorded from the hospital’s digital record system and patient files. Due to the lack of standard documentation in some patient files, 912 patients who met the appropriate criteria were included in the study.
Patients of all age groups with endometrial pathology were included in the study. Patients who were pregnant, had bleeding due to imminent or incipient abortion, suspected ectopic pregnancy, or abnormal uterine bleeding due to bleeding diathesis disorder were excluded.
These patients underwent pelvic examination, TVUSG, and office HSK (diagnostic) performed sequentially by the same gynecologist. Operative HSK was performed on patients based on the pathologies observed during office HSK.
TVUSG (DC-7, Mindray, Shenzhen, China) was performed at the time of the patient’s initial visit to the outpatient clinic, regardless of the patient’s menstrual phase. The probe was inserted into the vagina, and the cervix, cervical canal, endometrial cavity contours, and ovaries were evaluated using coronal and sagittal sections.
In this study, the uterine cavity and endometrium were evaluated as normal endometrium when they were clearly separated from the myometrium and appeared as a hyperechoic and regular line. All structures with different echogenicity and structures that disrupted the continuity of the uterine cavity and caused an irregular appearance were considered abnormal. Endometrial polyps were evaluated as hyperechoic masses with regular borders, varying in size and shape. Structures within the uterine cavity that were less echogenic than polyps and had a dense structure were evaluated as uterine myomas. Abnormalities such as myomas and polyps found in the cavity were recorded. Endometrial thickness was measured in the sagittal plane from the outer border of the endometrium at its thickest point to the outer border of the underlying endometrium. Patients with endometrial thickness above 5 mm in the postmenopausal period were evaluated as having increased endometrial thickness. Fluid in the endometrial cavity was not included in the measurement.
The hysteroscopy device used in office HSK was Olympus (Olympus, Tokyo, Japan), and the hysteroscope used in conventional hysteroscopy was MED-15 (Medikal Co., İstanbul, Turkey). The Office HSK procedure was performed under the supervision of an obstetrician-gynecologist with sufficient knowledge and skills, assisted by an intervention nurse with sufficient knowledge and experience regarding the device. The patients’ questions were answered. The consent form was signed.
Cases scheduled for office HSK were placed on the examination table in the lithotomy position. Prophylactic antibiotics were not used. The cervical canal was evaluated while passing through the cervical os. After entering the cavity, each tubal ostium and the walls of the uterine cavity were evaluated in detail using panoramic imaging. Pathologies detected during the procedure and their locations were noted in the system. Preparations for operative HSK were initiated in patients with detected pathologies. In patients with no pathology detected during office HSK but with symptoms such as abnormal uterine bleeding or postmenopausal bleeding, endometrial sampling was performed.
In operative HSK, endometrial polyps, submucosal myomas, intrauterine adhesions, and uterine septa that could be treated during the procedure were removed with the aid of a resectoscope. Endometrial sampling was performed in patients without any pathology. All samples taken were sent to the hospital’s pathology department.
Statistical Analysis
IBM SPSS Statistics 22 (IBM SPSS, Turkey) software was used for statistical analysis when evaluating the findings obtained in the study. The normality of the parameters was assessed using the Shapiro-Wilk test when evaluating the study data. In addition to descriptive statistical methods (mean, standard deviation, frequency), the Chi-square test and Fisher-Freeman-Halton test were used to compare qualitative data when evaluating the study data. Diagnostic screening tests were used in sensitivity and specificity calculations. Significance was evaluated at p<0.05.
Ethical Approval
This study was approved by the Ethics Committee of Taksim Training and Research Hospital (Date: 2019-01-30, No: 18).
Results
The ages of the women ranged from 20 to 82, with an average of 44.72±9.77. The demographic data of the patients are given in Table 1. Of the 47 women whose smoking status was known, 95.7% were smokers and 4.3% were non-smokers. We classified patients’ presenting complaints as premenopausal, postmenopausal, amenorrhea-oligomenorrhea, and other. We included patients describing menometrorrhagia, menorrhagia, metrorrhagia, hypermenorrhea, and hypomenorrhea in the premenopausal group; patients describing bleeding during the postmenopausal period or those with detected postmenopausal endometrial thickening in the postmenopausal group; and patients describing pelvic pain, infertility, postcoital bleeding, dysmenorrhea, vaginitis, and dyspareunia complaints in the group we called “other.”
The pathological results according to the groups of presenting complaints are presented in Table 1. There was a statistically significant difference in the distribution rates of pathology results among the complaint groups (p = 0.000; p < 0.05). The rate of polyps in the pathology results of the group presenting with other complaints (65.2%) was found to be statistically significantly higher than that of the postmenopausal (46.51%) and amenorrhea-oligomenorrhea (48.8%) groups (p1 = 0.002; p2 = 0.022; p < 0.05). The rate of polyps in the pathology results of the group presenting with premenopausal complaints (63.5%) was statistically significantly higher than that of the postmenopausal group (46.51%); however, the rate of malignancy (1.3%) was significantly lower than that of the postmenopausal group (11.63%) (p = 0.000; p < 0.05). There was no statistically significant difference in pathology results among the other complaint groups (p > 0.05).
The distribution of pathology results according to diagnostic methods is shown in Table 2. Pathology results confirmed polyps in 82.3% of cases, with ultrasound results indicating polyps. Pathology results confirmed fibroids in 67.3% of cases, with ultrasound results indicating fibroids. Of the cases with normal ultrasound results, 48.3% were diagnosed as polyps, and 49.1% were diagnosed as normal by pathology. Of the cases with other ultrasound results, 65.5% were diagnosed as normal by pathology. Of the cases with polyps according to office HSK results, 72.3% were also diagnosed as polyps according to pathology. Of the cases with fibroid on office HSK, 66.7% were also diagnosed as fibroid on pathology. Of the cases with normal findings on office HSK, 54.4% were diagnosed as polyps on pathology, and 39.2% were diagnosed as normal. Of the cases with other findings on office HSK, 62.2% were diagnosed as normal on pathology. Of the cases with polyps on operative HSK, 89.2% were also diagnosed as polyps on pathology. Of the cases with fibroids on operative HSK, 70% were also diagnosed as fibroids on pathology. Of the cases with normal operative HSK results, 48.5% were diagnosed as polyps on pathology, and 48.5% were diagnosed as normal. Of the cases with other findings on operative HSK, 50% were diagnosed as polyps on pathology, and 46.7% were found to be normal. Of the cases with polyp+fibroid on operative HSK, 75% were diagnosed as polyps on pathology.
The distribution of diagnostic methods for identifying pathology is shown in Table 3. Of the 668 cases with an abnormal pathology diagnosis, 609 (66.8%) were detected as abnormal on ultrasound. The sensitivity of ultrasound relative to pathology was 91.2%, specificity was 23.4%, positive predictive value (PPV) was 76.5%, and negative predictive value (NPV) was 49.1%. Of the 511 cases with an abnormal pathology diagnosis, 379 (51.8%) were detected as abnormal by office HSK. The sensitivity of office HSK compared to pathology was 74.2%, specificity was 38.5%, PPV was 73.6%, and NPV was 39.2%. Of the 350 cases diagnosed as abnormal by pathology, 333 (82.4%) were detected as abnormal by operative HSK. The sensitivity of operative HSK relative to pathology was 95.1%, specificity was 29.6%, PPV was 89.8%, and NPV was 48.5%.
Discussion
In this study, the success rates of methods used in the diagnosis of endometrial pathologies were evaluated, and operative hysteroscopy was determined to be the most effective method. Visual examination-based diagnostic methods were found to have lower accuracy rates compared to ultrasonography, and ultrasonography was found to perform better than office hysteroscopy. These findings suggest that the physician’s experience and expertise may play a critical role in the effectiveness of imaging methods [7].
In this study, polyps were the most frequently detected finding in both intraoperative hysteroscopic observation and histopathological examination. Similarly, in the study by Altınbaş et al., polyps were the most frequently detected finding in intraoperative hysteroscopic observations, while histopathological examinations largely resulted in endometrial polyp diagnoses [8]. Although the results of the study are largely consistent with the literature, it should be noted that they may vary depending on the characteristics of the patient population. The high polyp rate found in the study is thought to be due to the large number of patients and the fact that our sample consisted largely of patients in the reproductive and premenopausal periods. Furthermore, the evaluation of endometrial differences within the ‘normal’ group may have led to a relatively high normal rate in the pathology results. The small number of postmenopausal patients may explain the low malignancy rate.
In the study by Çepni et al., it was found that TVUSG and sonohysterography (SIS) had limited sensitivity in the diagnosis of endometrial polyps in the postmenopausal period, whereas diagnostic accuracy was significantly increased with hysteroscopy [9]. In a retrospective analysis by Cengiz et al., it was reported that the most frequently detected pathology in cases undergoing operative hysteroscopy was endometrial polyps, while myomas were seen at lower rates [10]. The findings of the obtained study are largely consistent with the literature.
Alborzi et al. reported that the diagnostic accuracy of TVUSG was limited, whereas SIS provided higher sensitivity and specificity [11]. Similarly, Yıldırım et al.’ study also revealed that TVUSG showed moderate performance in identifying intracavitary lesions [12]. Furthermore, it was determined that abnormal cases detected by TVUSG showed high sensitivity but low specificity.
The effectiveness of HSK in the diagnosis of endometrial pathologies is well known. In this study, office HSK yielded acceptable results in terms of sensitivity and positive predictive value, but specificity and negative predictive value were lower. The literature indicates that the sensitivity rates of hysteroscopy are generally reported to be high [13-15]. The results of operative HSK were found to have a very high sensitivity, consistent with the literature, while similarly limited values were obtained in terms of specificity [16]. In a study investigating the diagnostic accuracy of HSK in perimenopausal and postmenopausal women, high sensitivity was reported for benign endometrial pathologies [17]. In a prospective study conducted by Al-Asadi on 60 women, the diagnostic performance of HSK varied; sensitivity was 100% for polyps, 83% for fibroids, and 84.2% for endometrial hyperplasia, while sensitivity for endometrial cancer was reported to be only 50%. The study also emphasized that specificity values were low. These findings show that the low specificity rates in our series are also observed in the literature and that HSK may be limited, especially in the diagnosis of malignancy. Therefore, it is once again emphasized that HSK findings must be supported by histopathological examination [18].
The low specificity of operative HSK is primarily due to physiological changes in the endometrium, benign polypoid structures, or subendometrial bleeding foci being mistakenly interpreted as pathological lesions, which increases false positive rates. Operator inexperience, lack of confirmatory second operator evaluation, inadequate viewing angle, or technical problems can also negatively affect diagnostic accuracy. Furthermore, heterogeneous lesions or small superficial foci may appear pathological during hysteroscopy but may not yield meaningful findings on histopathological examination. In addition, diagnostic discrepancies due to heterogeneity may arise in pathology sampling, which is considered the gold standard, leading to inconsistent results with hysteroscopy. Particularly in postmenopausal cases, findings such as endometrial atrophy and irregular bleeding can easily be confused with pathological processes, contributing to low specificity.
However, there are studies in the literature reporting higher diagnostic efficacy of HSK with biopsy. Indeed, in a large-scale retrospective cohort analysis conducted by Öztürk et al. on 2054 premenopausal women, biopsy performed with HSK provided the highest diagnostic accuracy, and specificity values were also reported as the highest among all methods [19]. In a retrospective analysis conducted by Khalife et al. on a large patient series, the diagnostic performance of endometrial sampling guided by hysteroscopy was evaluated, and high sensitivity and specificity values were found [20]. This difference may be due to the retrospective design, operator experience, and differences in the criteria used for evaluation. Therefore, it is thought that the hysteroscopy-guided biopsy method may make an important contribution, particularly in increasing specificity, and should be preferred in future studies. Of study this
A study by Garutti et al. on postmenopausal cases reported that HSK has a very high sensitivity and specificity [21]. In this study, office HSK also showed high sensitivity in the postmenopausal group, but a significant limitation was observed in terms of specificity. TVUSG showed moderate performance in the diagnosis of endometrial polyps, while office HSK fell below the reported values in the literature [22,23]. This difference can largely be attributed to operator inexperience.
In the diagnosis of submucosal fibroids, the literature indicates that office HSK offers a wide range of sensitivity [18-23]. In this study, operative HSK demonstrated high sensitivity and specificity in detecting fibroids, while office HSK showed lower sensitivity. This situation may be due to the inability to fully evaluate fibroids with office HSK or their confusion with polyps.
When the need for additional treatment was evaluated in patients who underwent hysteroscopy, it was determined that 91.2% of 875 cases did not require additional treatment. The need for additional treatment after hysteroscopic polypectomy has been reported to be between 8-10% in the literature [24]. In this study, the complication rate after the procedure was determined to be 1.4%. The complication rate was reported as 3.3% in the study by Cengiz et al. and 3% in the study by Karakaş et al. [10,25]. These results show that the complication rate in our study is lower than that reported in the literature.
Limitatitons
The retrospective design of our study constitutes a significant methodological limitation. Retrospective design increases the risk of selection bias in patient selection and may lead to information bias depending on how the data is recorded. This situation may negatively affect diagnostic accuracy and reliability, particularly during retrospective evaluation of clinical findings and imaging results. Furthermore, the low specificity values obtained in our study led to more frequent false-positive results and limited the direct generalizability of the findings to clinical practice. Office HSK results may have been affected by the operator’s learning curve and the difficulties encountered, particularly in distinguishing between polyps and submucosal fibroids. This may explain why office hysteroscopy in this study had lower sensitivity compared to the literature. A significant limitation of this study is the relatively small number of postmenopausal cases. This has reduced the ability to detect malignancy and limited the generalizability of the results. Further studies involving larger patient populations, particularly with a higher representation of postmenopausal women, are needed.
Although this study had a large number of patients, was performed by a single operator, and compared different techniques, it was not evaluated in conjunction with a cost analysis. Multicenter studies conducted with cost analyses could contribute to the literature.
Conclusion
Operative HSK has been shown to be the method with the highest success rate in the diagnosis of endometrial pathologies. Due to the low sensitivity of HSK in endometrial hyperplasia, the necessity of obtaining a biopsy, especially in suspicious cases, should be emphasized. All three methods have different advantages and are recommended to be used together in patient treatment planning.
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, and 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.
References
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6. Dede M. Jinekolojik onkolojide histeroskopinin yeri [The place of hysteroscopy in gynecologic oncology]. Gülhane Tıp Derg. 2002;44 (4):464 -71.
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11. Alborzi S, Parsanezhad ME, Mahmoodian N, Alborzi S, Alborzi M. Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding. Int J Gynaecol Obstet. 2007;96(1):20-3.
12. Yıldırım G, Fıçıcıoğlu C, Attar R, Karateke A, Yeşildağlar N. İnfertilite tedavisi öncesi uterin kavite değerlendirilmesinde transvajinal ultrasonografi ve ofis histeroskopinin karşılaştırılması [Comparison of transvaginal ultrasonography and office hysteroscopy in the evaluation of uterine cavity before infertility treatment]. Zeynep Kamil Med J.2009;40(4):167-71.
13. Yiğit A, Güzin K, Afşar S, Süer N. Anormal uterin kanamalı premenopozal kadınlarda transvaginal ultrasonografi, salin infüzyon sonografi ve histeroskopi sonuçlarının karşılaştırılması [Comparison of transvaginal ultrasonography, saline infusion sonography, and hysteroscopy findings in premenopausal women with abnormal uterine bleeding]. Göztepe Tıp Derg. 2009;24(2):52-8
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Elif Uçar, Melih Bestel, Bülent Babaoğlu, Süleyman Salman, Comparison of transvaginal ultrasound, office hysteroscopy, and operative hysteroscopy results in patients with detected endometrial pathology. Ann Clin Anal Med 2025;16(Suppl 3):S182-187
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Evaluation of advanced life support knowledge and practices across medical specialties: A cross-sectional survey
Neslihan Ergün Süzer 1, Hayri Canbaz 2, Özgür Sirkeci 3, Emel Erkuş Sirkeci 4
1 Department of Emergency Medicine, Kocaeli Darıca Farabi Training and Research Hospital, Kocaeli, Türkiye, 2 Department of Emergency Medicine, Yıldırım Beyazıt University, Ankara Yenimahalle Training and Research Hospital, Ankara, Türkiye, 3 Department of Gastroenterology, Isparta City Hospital, Isparta, Türkiye, 4 Department of Emergency Medicine, Isparta City Hospital, Isparta, Türkiye
DOI: 10.4328/ACAM.22913 Received: 2025-09-24 Accepted: 2025-10-23 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S188-191
Corresponding Author: Neslihan Ergün Süzer, Department of Emergency Medicine, Kocaeli Darıca Farabi Training and Research Hospital, Kocaeli, Türkiye. E-mail: drergunsuzer@gmail.com P: +90 506 482 06 83 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4839-8110
Other Authors ORCID ID: Hayri Canbaz, https://orcid.org/0000-0001-6989-7854 . Özgür Sirkeci, https://orcid.org/0000-0001-9048-5096 . Emel Erkuş Sirkeci, https://orcid.org/0000-0003-2743-7619
This study was approved by the Ankara City Hospital No. 2 Clinical Research Ethics Committee (Date: 2022-12-07, No: E2-22-2965)
Aim: This study aimed to evaluate the knowledge and experience levels of physicians from different specialties regarding advanced life support (ALS).
Materials and Methods: A cross-sectional survey was conducted between May 1 and November 1, 2022, among 151 physicians (70.9% internal medicine; 29.1% surgical) working at a tertiary training and research hospital. A 14-item questionnaire was designed based on the 2020 AHA ALS guidelines and distributed online. Participants’ specialties, years of professional experience, and prior ALS training were assessed. Data were analyzed using SPSS 24.0, and categorical variables were compared using Pearson’s chi-square test.
Results: Of the participants, 80.8% had less than 10 years of professional experience. The rate of correct responses differed significantly by specialty. Physicians in internal medicine showed higher accuracy rates than surgical physicians in chest compression rate (p = 0.001), drug protocols (p = 0.001), and defibrillation rhythm selection (p = 0.010). No statistically significant differences were found in overall accuracy rates based on years of experience (p > 0.05).
Discussion: Knowledge of ALS varies across specialties, with internal medicine physicians demonstrating higher proficiency in certain critical areas. However, years of professional experience were not a determining factor. The findings highlight the importance of regular, multidisciplinary ALS training.
Keywords: advanced life support, cardiopulmonary resuscitation, intubation, emergency physicians, knowledge, experience
Introduction
Advanced life support (ALS) is a set of interventions applied in cardiac arrest or life-threatening emergencies, extending beyond basic life support and requiring advanced skills. Its main components include effective cardiopulmonary resuscitation (CPR), airway management, defibrillation, and pharmacological interventions [1,2]. These measures are essential to reduce mortality and morbidity.
Among these, airway management is particularly critical, as failure to secure the airway renders other interventions ineffective. Endotracheal intubation is considered the cornerstone of ALS; however, incorrect or prolonged procedures may cause serious complications, such as post-intubation tracheal stenosis [3,4]. Therefore, both technical competence and adequate training are vital.
The American Heart Association (AHA) guidelines provide a global framework for ALS, with the 2020 update forming the basis of this study’s questionnaire [5]. The guidelines emphasize high-quality CPR, appropriate airway strategies, and timely pharmacological treatment. In addition, recent research highlights the benefits of preoxygenation during intubation and the positive impact of structured training, even among non-medical staff [6-8].
In Turkey, surveys have revealed variability in physicians’ knowledge of rapid sequence intubation and cardiopulmonary resuscitation across specialties [9,10]. Assessing these differences is important for identifying training needs. In this study, we compared ALS knowledge among physicians from surgical and internal medicine specialties, as well as by years of professional experience.
Materials and Methods
This study was conducted as a cross-sectional survey between May 1 and November 1, 2022. Physicians working at a tertiary training and research hospital were included. Participants consisted of specialists, residents, and general practitioners from internal medicine and surgical departments. Participation was entirely voluntary, and only physicians who had been actively practicing for at least one year were eligible. Physicians who did not complete the questionnaire in full were excluded from the analysis.
The questionnaire was developed based on the 2020 American Heart Association (AHA) advanced life support (ALS) guidelines. It consisted of knowledge-based items on cardiopulmonary resuscitation algorithms, airway management, intubation practices, defibrillation, and pharmacological interventions, as well as demographic sections that addressed participants’ specialties, years of professional experience, ALS training background, and practical application experience. Data were collected anonymously through online forms, and each participant was allowed to respond only once.
Statistical Analysis
Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 24.0. Descriptive statistics were presented as frequencies and percentages. Pearson’s chi-square test was used to compare categorical variables (specialty, years of experience, and responses). This test was preferred as it is appropriate for assessing independence between categorical data. A significance level of p< 0.05 and p < 0.01 was considered statistically significant.
Ethical Approval
This study was approved by the Ankara City Hospital No. 2 Clinical Research Ethics Committee (Date: 2022-12-07, No: E2-22-2965).
Results
When the departmental distribution was examined, 29.1% (n = 44) of the participants were from surgical departments and 70.9% (n = 107) from internal medicine. Most had less than 10 years of experience (80.8%, n = 122). In out-of-hospital cardiac arrest, 57.0% (n = 86) reported that high-quality CPR should be initiated immediately, while 39.7% (n = 60) chose activation of emergency medical services. The correct chest compression rate (100–120/min) was identified by 54.3% (n = 82), and ventricular fibrillation was recognized as a defibrillable rhythm by 87.4% (n = 132). For adrenaline administration in shockable rhythms, 60.3% (n = 91) selected “after the second shock (Table 1).
In department-based comparisons, internal medicine physicians more frequently identified the correct chest compression rate, drug protocol, defibrillable rhythm, and the unnecessary nature of the precordial thump (all p < 0.01). They were also more confident in managing CPR with ancillary staff only (p = 0.020). Although not statistically significant, they showed higher awareness of capnography use compared with surgical physicians (p = 0.053) (Table 2).
With years of professional experience, no statistically significant differences were observed in most responses. Physicians with ≥10 years of experience showed slightly higher accuracy in drug protocol and defibrillable rhythm recognition; however, these did not reach statistical significance. The only significant difference was observed in the precordial thump question, where physicians with less than 10 years of experience more often selected “unnecessary” (p = 0.001). Confidence in managing CPR with ancillary staff only was higher among more experienced physicians, although not statistically significant (p = 0.069) (Table 3).
Discussion
In this study, the knowledge and practice levels of internal medicine and surgical physicians regarding advanced life support (ALS) in a tertiary care hospital were compared, along with an assessment of ALS knowledge and practice levels according to physicians’ years of professional experience.
When the responses to the 14 survey questions were analyzed, no statistically significant differences were observed in 13 questions between physicians with longer professional experience and other groups. This finding suggests that, rather than years of experience, differences between specialties play a more prominent role in ALS knowledge and practice. Furthermore, the lack of significant variation in overall knowledge by professional experience indicates that knowledge retention and adherence to current guidelines are not solely dependent on clinical seniority. In contrast, a study conducted by Küçükceran et al. in Erzurum in 2021, which assessed CPR knowledge among 251 residents and specialists, reported that physicians with more than 15 years of experience had significantly lower rates of correct responses compared to other groups. Their study emphasized the importance of regular training and updates, particularly for physicians in specialties less frequently exposed to CPR, and highlighted the necessity of practical training for all physicians [11].
The 2020 AHA guidelines underscore that high-quality CPR (with correct rate and depth of compressions, and minimal interruptions) and appropriate drug administration have a critical impact on survival; therefore, the deficiencies in compression rate and pharmacological knowledge observed in this survey are clinically significant [5]. In contrast to Karaca et al., who reported in their 2024 study of 163 participants that ALS knowledge levels were higher among surgical specialists than internal medicine specialists [12], our study found that internal medicine physicians demonstrated higher accuracy in chest compression rate, drug protocol selection, and recognition of defibrillable rhythms. These differences may be attributable to the distinct clinical focuses and training priorities of different specialties; surgical physicians may have fewer opportunities for practical management of acute cardiac events, which could theoretically explain this discrepancy.
From an educational perspective, regular, hands-on ALS training, multidisciplinary scenarios, and periodic refresher examinations are recommended. The existence of survey-based studies in Türkiye that reflect local practice variations (e.g., national surveys on rapid sequence intubation) further supports the need for tailored educational strategies that address country-specific requirements [9].
In light of these findings, ALS training should be delivered in a multidisciplinary manner, with regular updates; institutional simulation programs and practical training, particularly for surgical specialties, should be expanded; and the role of certification or competency examinations should be strengthened. Moreover, since this study was conducted in a single center, its generalizability is limited, and future multicenter studies are needed to validate these findings.
Limitations
This study has some limitations. First, it was conducted in a single tertiary care hospital, which may limit the generalizability of the findings. Second, the data were collected through a self-administered questionnaire, which may be subject to recall or reporting bias. Finally, the cross-sectional design prevents establishing causal relationships between specialty, professional experience, and ALS knowledge. Future multicenter and longitudinal studies are warranted to validate and expand these results.
Conclusion
In this single-center study, we observed significant differences in advanced life support knowledge between internal medicine and surgical physicians, with the former group demonstrating higher proficiency in several critical areas. Years of professional experience were not associated with improved knowledge levels. These findings emphasize the importance of continuous, structured, and multidisciplinary ALS training programs for physicians across all specialties.
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, and 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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Neslihan Ergün Süzer, Hayri Canbaz, Özgür Sirkeci, Emel Erkuş Sirkeci, Evaluation of advanced life support knowledge and practices across medical specialties: A cross-sectional survey. Ann Clin Anal Med 2025;16(Suppl 3):S188-191
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The Impact of the inflammatory process and biomarkers in recurrent urethral stricture
Nazım Abdulkadir Kankılıç
Department of Urology, Faculty of Medicine, Aksaray University, Aksaray, Turkey
DOI: 10.4328/ACAM.22914 Received: 2025-09-25 Accepted: 2025-10-23 Published Online: 2025-10-23 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S192-195
Corresponding Author: Nazım Abdulkadir Kankılıç, Department of Urology, Faculty of Medicine, Aksaray University, Aksaray, Turkey. E-mail: nakankilicdr@hotmail.com P: +90 542 673 84 47 Corresponding Author ORCID ID: https://orcid.org/0000-0002-3747-3798
This study was approved by the Ethics Committee of Aksaray University (Date: 2025-08-14, No: 2025/62)
Aim: Urethral stricture is a clinical condition characterized by fibrosis of the urethral mucosa, often recurrent, and frequently requiring hospitalization and surgical intervention. Various inflammatory markers, such as the Systemic Inflammatory Index, have been reported to increase in recurrent urethral strictures and be effective in predicting recurrence. This study aimed to evaluate the role of inflammatory processes and markers in patients who underwent internal urethrotomy and to determine their relationship with recurrence.
Materials and Methods: Male patients aged 18–80 years who underwent urethral surgery and had complete data were included in the study. Hemogram parameters, platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), AST/ALT ratio, and patient comorbidities were analyzed. Patients were divided into recurrent and non-recurrent groups after internal urethrotomy.
Results: Recurrence was statistically higher in patients with diabetes mellitus (p < 0.05). No significant differences were observed between the groups in laboratory parameters such as WBC, lymphocyte, and platelet counts, or in ratios such as AST/ALT, PLR, and NLR. However, CRP levels were significantly higher in the recurrent group compared to the non-recurrent group (p < 0.05).
Discussion: The recurrence rate of urethral stricture was higher in patients with chronic diseases such as diabetes mellitus and hypertension. Our findings suggest that the presence of diabetes mellitus increases the likelihood of recurrence following internal urethrotomy and that elevated CRP levels at admission may be a predictive marker for recurrence.
Keywords: biomarkers, inflammation, urethral stricture, inflammatory markers
Introduction
Urethral stricture is a clinical condition that develops as a result of fibrosis of the urethral mucosa, often recurrent in nature, and frequently requiring hospitalization and surgical intervention [1]. In addition to inflammation, etiological factors include sexually transmitted infections, iatrogenic urethral trauma (such as catheterization), perineal trauma, and a history of prostate surgery [2,3]. The incidence of urethral stricture is reported to be between 23 and 63 per 10,000 individuals, with the most common localization being the bulbar urethra among anterior urethral strictures [4]. Treatment options include internal urethrotomy, urethral dilatation, and open surgery such as urethroplasty [2,4]. Despite a reported success rate of 8–77% for internal urethrotomy, the recurrence rate of urethral stricture remains high [3,4]. One of the reasons for this high recurrence is that internal urethrotomy itself contributes to scar formation [4].
In recent years, inflammation has been shown to be closely associated with urethral stricture, and inflammatory processes are considered significant contributing factors in its pathogenesis [5]. In an experimental rat model of urethral stricture, inflammatory parameters were found to be increased, with a marked and severe inflammatory response demonstrated in the stricture group [5,6]. Furthermore, urethral inflammation and infiltration of inflammatory cells have been identified as key factors in the development of stricture [7]. Elevated inflammatory markers, such as the Systemic Inflammatory Index (SII), have also been reported in recurrent urethral stricture, and these markers may play an important role in predicting recurrence [6]. Several studies have recognized systemic inflammatory markers as reflections of the body’s overall inflammatory response [8-16].
Based on this background, the present study aimed to evaluate inflammatory processes and markers in patients who underwent internal urethrotomy for urethral stricture, comparing those with and without recurrence during follow-up, in order to determine their potential role in predicting recurrence.
Materials and Methods
This retrospective study was conducted at the Department of Urology, Aksaray Training and Research Hospital, between January 2022 and January 2025. The study population consisted of male patients over the age of 18 who were diagnosed with urethral stricture and underwent internal urethrotomy.
Inclusion criteria were male patients aged 18–80 years with complete clinical and laboratory data who had undergone urethral surgery. Exclusion criteria included patients with active inflammatory processes due to systemic diseases, those with active infections, patients who underwent internal urethrotomy as an emergency procedure, individuals younger than 18 or older than 80 years, female patients, and patients with incomplete data.
Demographic, clinical, and laboratory data of the included patients were obtained from the hospital information system, electronic medical records, and patient files. Routine laboratory tests, including hemogram parameters, were retrieved from preoperative blood samples. The platelet-to-lymphocyte ratio (PLR) was calculated as the ratio of platelet to lymphocyte counts, the neutrophil-to-lymphocyte ratio (NLR) as the ratio of neutrophil to lymphocyte counts, and the AST/ALT ratio (De Ritis ratio) as the ratio of aspartate aminotransferase to alanine aminotransferase.
Patients were divided into five groups based on comorbidities: diabetes mellitus (DM), hypertension (HT), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and others. They were further classified into two groups according to recurrence: patients who developed urethral stricture within six months or later after internal urethrotomy (recurrence group) and those who did not (non-recurrence group). Inflammatory markers were compared between the two groups.
The study was conducted in accordance with the principles of the Declaration of Helsinki. Owing to its retrospective design, informed consent was not required.
Statistical Analysis
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used for the demographic characteristics of the patients. The Chi-square test and Mann-Whitney U test were employed to compare the proportions of categorical variables. The association between chronic diseases and recurrence was evaluated using the Chi-square test. Numerical data were expressed as mean ± standard deviation (SD) and minimum–maximum values. A p-value of <0.05 was considered the threshold for statistical significance in all analyses.
Ethical Approval
The study was approved by the Ethics Committee of Aksaray University (Date: 2025-08-14, No: 2025/62).
Results
A total of 79 patients were included in the study, consisting of 41 patients with recurrent urethral stricture (UD) after the first internal urethrotomy and 38 patients without recurrence. The study flow diagram is presented in Figure 1. The mean age of patients in the recurrent UD group was 65.6 ±16.7 years, which was not significantly different compared to the non-recurrent group (p = 0.134). In the recurrent group, diabetes mellitus (DM) was present in 28 patients (68.2%), which was significantly higher compared to the non-recurrent group (p<0.05). The comparison of demographic characteristics between the two groups is summarized in Table 1. No significant differences were observed between the two groups in laboratory parameters such as WBC, lymphocyte, and platelet counts, or in ratios including AST/ALT, PLR, and NLR. However, CRP levels were found to be significantly higher in the recurrent group compared to the non-recurrent group (p < 0.05).
The comparison of laboratory values between the two groups is presented in Table 2.
Discussion
Urethral stricture is one of the oldest and most challenging diseases in urology. It is most frequently seen between the ages of 20 and 70, while it is rare outside this age range. This contradicts the notion that the incidence of stricture increases proportionally with age, particularly after the age of 55 [17]. The success of treatment depends not only on the choice of modality but also on the location and length of the stricture [18]. Internal urethrotomy is generally the first-line treatment, whereas open urethroplasty remains the most effective option in recurrent cases. While primary strictures are often idiopathic or iatrogenic, multiple factors contribute to recurrence. Identifying these factors and implementing preventive measures may reduce recurrence rates. Chronic comorbidities such as diabetes mellitus (DM) and hypertension (HT) have been associated with higher recurrence rates [5]. In our study, we found that DM was a significant factor increasing recurrence after internal urethrotomy, and elevated CRP levels at admission were also higher in the recurrence group. Kinnaird et al. reported in a series of 604 patients that the mean age of patients with recurrent urethral stricture was 44.5 years, and being over 50 years was a risk factor for recurrence [2]. Similarly, Blaschko et al. found the median age of recurrence cases to be 44 (11–75), and Van Dyke et al. reported a mean age of 51.6 years [19,20]. In contrast, the mean age in our study was 65.6 years, which is higher compared to previous studies; this may be related to our exclusion criteria.
Chapman et al., in a series of 595 patients who underwent bulbar urethroplasty, identified DM, HT, obesity, and infectious diseases as risk factors for recurrence [21]. Gul et al. also reported that the frequency of DM and HT was higher in patients with recurrent stricture [22]. In line with these studies, we demonstrated that DM was more frequent in patients with recurrence compared to those without recurrence.
Bagchi et al., in a study of 105 patients, reported higher CRP levels in patients with recurrent stricture (11.54 ± 3.64) compared to those with successful outcomes [23]. Similarly, Tokuç et al. found that CRP levels in patients with recurrence were 4.5±2.1, nearly twice as high as in non-recurrent cases [24]. Consistent with these findings, our study also showed that CRP levels were significantly elevated in patients with recurrence.
Gul et al. reported that PLR, but not NLR, was a risk factor for urethral stricture developing after transurethral resection of the prostate [25]. In contrast, Urkmez et al., in a study of 512 patients with recurrent stricture, found that NLR was elevated and could predict recurrence after surgery [18]. Another study reported that PLR and SII were significant predictors of recurrence, while NLR was not [23]. As seen, no specific inflammatory marker has yet been universally accepted for predicting recurrent urethral stricture. In agreement with this, our study found no significant differences in NLR or PLR between patients with and without recurrence.
This study has some limitations. First, it was conducted at a single center with a relatively small sample size, which may limit the generalizability of the findings. Second, due to its retrospective design, certain clinical data could not be fully evaluated. Finally, long-term follow-up data were not available; therefore, late complications could not be assessed. Future studies with larger populations and prospective designs will be necessary to strengthen the clinical utility of inflammatory markers in predicting recurrent urethral stricture.
Limitations
This study has several limitations. First, its retrospective design may have introduced selection bias and limited the ability to establish causal relationships. Second, the sample size was relatively small and derived from a single center, which may restrict the generalizability of the results. Third, only a limited number of inflammatory markers were evaluated; other systemic or local inflammatory parameters that might influence recurrence risk were not assessed. Additionally, the follow-up duration and patient adherence to postoperative care may have affected recurrence rates. Therefore, larger, prospective, and multicenter studies are needed to confirm these findings and clarify the underlying mechanisms.
Conclusion
In conclusion, urethral stricture is a frequent ailment in men, and more than half of those who undergo internal urethrotomy have a recurrence during follow-up. In our investigation, CRP levels were considerably greater in individuals with recurrent urethral stricture, but other inflammatory markers revealed no significant changes. Furthermore, diabetes mellitus was associated with an increased risk of recurrence. These data imply that increased CRP levels and diabetes mellitus may be objective predictors of recurrence following internal urethrotomy. Prospective, multicenter investigations are required to validate these findings and further understand their therapeutic value.
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, and 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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7. Aydın A, Oltulu P, Balasar M, et al. The role of prostate inflammation in the pathogenesis of urethral strictures occurring after transurethral resections. Rev Int Androl. 2022;20(2):86-95.
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13. Erdal H, Kılıc AO, Akbulut Yagcı B, et al. Can the pan-immune inflammation value, systemic inflammatory response index, and other hematological inflammatory indices be clinically used to predict pseudoexfoliation? J Clin Pract Res. 2024;46(1):19-23.
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16. Erdal, H, Giynas Ayhan, M. Inanli, I. Evaluation of Calprotectin and Other İnflammatory Parameters in Patients with Schizophrenia. Bratisl Med. J. 2025;126(10):2674-9.
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Nazım Abdulkadir Kankılıç. The Impact of the inflammatory process and biomarkers in recurrent urethral stricture. Ann Clin Anal Med 2025;16(Suppl 3):S192-195
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Removable folded sterile gauze compression
Göksever Akpınar, Batuhan Eyduran
Department of General Surgery, Faculty of Medicine, Health Sciences, University Izmir Tepecik Training and Research Hospital, Izmir, Turkey
DOI: 10.4328/ACAM.22915 Received: 2025-09-25 Accepted: 2025-10-23 Published Online: 2025-10-25 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S196-201
Corresponding Author: Batuhan Eyduran, Department of General Surgery, Faculty of Medicine, Health Sciences, University Izmir Tepecik Training and Research Hospital, Izmir, Turkey. E-mail: batuhaneyduran@yahoo.com.tr P: +90 555 601 13 01 Corresponding Author ORCID ID: https://orcid.org/0000-0003-0751-2538
Other Authors ORCID ID: Göksever Akpınar, https://orcid.org/0000-0002-0648-7767
This study was approved by the Ethics Committee of Health Sciences University, Izmir Tepecik Training and Research Hospital (Date: 2024-03-24, No:2024/03-24)
Aim: This study aims to evaluate patients who underwent intra-abdominal packing due to bleeding during emergency or elective surgeries and to introduce the Easily Removable Folded Sterile Gauze Compression Method (ERFSGCM) and its clinical outcomes.
Materials and Methods: Patients who applied packing for uncontrolled bleeding between 2015 and 2023 were retrospectively analyzed. Two groups were compared: traditional packing and ERFSGCM. Data included demographics, Charlson Comorbidity Index (CCI), INR levels, surgical details, trauma type, bleeding site, packing method, number of quadrants packed, blood loss and transfusions, abdominal closure technique, timing of fascia closure, recurrent bleeding, number of surgeries, postoperative complications (renal failure, ischemia, respiratory distress, wound infection), Clavien-Dindo scores, ventilation duration, ICU/hospital stay, and mortality.
Results: Twenty-nine patients were included: 25 with traditional packing and 4 with ERFSGCM. Mean age was 51.6 ± 19.2 years. No significant difference was found in demographics or CCI. Emergency surgeries accounted for 55.2%. Recurrent bleeding, number of surgeries, acute renal failure, and mortality were significantly lower in the ERFSGCM group (p < 0.05). All ERFSGCM patients had Clavien-Dindo scores of 2, while traditional packing patients scored above 2 (p < 0.001). Fascia closure was more frequent in the ERFSGCM group (p = 0.030).
Discussion: ERFSGCM may reduce the need for re-laparotomy and improve outcomes compared to traditional packing. Further studies with larger cohorts are needed to confirm its efficacy.
Keywords: bleeding, hemorrhage, compression, packing, trauma
Introduction
Hemorrhage remains the leading cause of preventable death in trauma patients [1–3]. The pressure-packing technique, initially used during World War II, was largely abandoned due to infection and coagulopathy-related rebleeding, until Lucas and Ledgerwood’s prospective study of 637 patients reintroduced and evaluated its efficacy [4].
Management of hemorrhagic trauma and postoperative coagulopathy remained uncertain until Rotondo et al. (1993) highlighted the “triad of death”—acidosis, coagulopathy, and hypothermia—prompting the adoption of damage control surgery with resuscitation. Although it was first attempted a century ago and applied during the last century, its significance was only recently recognized, with Rotondo’s study establishing it as the primary approach for major trauma. Currently, early recognition of bleeding remains a key determinant of survival [5–6]. The goal of post-trauma laparotomy is to control hemorrhage from intra-abdominal organs, vascular injuries, and retroperitoneal trauma.
Routine four-quadrant packing is widely practiced for hemorrhage control [7–9]. However, consensus is lacking on whether packing should target all quadrants or only the bleeding site, and the optimal abdominal closure technique after damage control surgery remains unclear [10]. This study evaluates patients who underwent packing for intra-abdominal bleeding during emergency or elective surgery and introduces the Easily Removable Folded Sterile Gauze Compression Method (ERFSGCM) as a potential alternative.
Traditional Packing Method
1. Direct packing of the bleeding site with dry 15×40 cm gauze.
2. Additional gauze was placed adjacent to enhance tamponade.
3. Manual pressure applied for 10–15 minutes.
4. If hemostasis was inadequate, further gauze was applied to the edges; in extensive bleeding, laparotomy pads (40×40 cm) were also used.
5. The bowel was protected with a wet towel.
6. Temporary abdominal closure was performed with single-layer skin sutures using 1-0 material [11].
Easily Removable Folded Sterile Gauze Compression Method
ERFSGCM uses 30-meter sterile gauze strips instead of traditional compresses. The gauze is unfolded and folded layer by layer with forceps to achieve compression, and one end is exteriorized through a small abdominal incision. This design enables bedside removal of the packing 48 hours postoperatively, eliminating the need for re-laparotomy.
Materials and Methods
Clinical Data Collection
Inclusion: All cases that underwent packing for uncontrollable bleeding at Health Sciences University Tepecik Training and Research Hospital (Izmir/Turkey) from 2015 to 2023 were retrospectively reviewed using the hospital database (Probel HBYS v1, Izmir, Turkey).
Exclusion: Cases with missing data in the hospital records were excluded from the study.
Patients were classified into two groups: traditional packing and ERFSGCM. Data collected included demographics, Charlson Comorbidity Index (CCI), preoperative INR, surgical indication and type, iatrogenic bleeding in elective cases, trauma type, bleeding site, packing method, number of quadrants packed, intraoperative blood loss and transfusions, abdominal closure technique, timing of final fascial closure, recurrent bleeding after unpacking, number of surgeries, postoperative complications (acute renal failure, ischemic events, respiratory distress, wound infection), Clavien-Dindo scores, duration of mechanical ventilation, ICU and hospital stay, and mortality. Statistical analyses were performed.
Statistical Analysis
Statistical analyses were performed using SPSS v. 25. Normality was assessed with Kolmogorov-Smirnov and Shapiro-Wilk tests. Data were expressed as mean ± SD for normally distributed variables and as median (Q1–Q3) for non-normal variables; categorical data were presented as frequency and percentage. Group comparisons used the independent samples t-test or Mann-Whitney U test for continuous variables, and Pearson’s chi-square or Fisher’s exact test for categorical variables. Univariate analyses identified potential risk factors, followed by multivariate analyses to determine independent predictors. A p-value<0.005 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Health Sciences University, Izmir Tepecik Training and Research Hospital (Date: 2024-03-24, No:2024/03-24).
Results
Twenty-nine patients were included: 25 underwent traditional packing and 4 applied ERFSGCM. The mean age was 51.6±19.2 years (traditional: 53.7±18.8; ERFSGCM: 38.5±18). Overall, 19 patients (65.5%) were male. In the traditional group, 15 (60%) were male and 10 (40%) female, while all ERFSGCM patients were male. No significant differences were observed between groups regarding demographic distribution (p = 0.143, p = 0.268). The median CCI was 4 (0–6) overall, 4 (1–6) in the traditional group, and 0 (0–3) in the ERFSGCM group (p = 0.070). Among all surgeries, 16 (55.2%) were emergencies and 13 (44.8%) were elective. In the traditional group, 52% were emergency and 48% elective, while in the ERFSGCM group, 75% were emergency and 25% elective, with no significant difference between groups (p = 0.606). All emergency surgeries involved trauma. Trauma types were blunt in 9 patients (56.3%), penetrating in 3 (18.8%), and high-energy in 4 (25%). In the traditional packing group, 9 (69.2%) had blunt, 2 (15.4%) penetrating, and 2 (15.4%) high-energy trauma. In the ERFSGCM group, 1 (33.3%) had penetrating and 2 (66.7%) high-energy trauma; no blunt trauma was observed. Differences in trauma distribution were not significant (p = 0.080). Among elective surgeries, 10 patients (71.4%) had iatrogenic bleeding: 9 (69%) in the traditional group and 1 (100%) in the ERFSGCM group, with no significant difference (p = 1.000). Bleeding sites included the liver in 11 patients (37.9%; traditional 32%, ERFSGCM 75%), the presacral area in 8 (27.6%; traditional 28%, ERFSGCM 25%), and the retroperitoneum in 8 (27.5%; all traditional, most commonly Zone 2a). No ERFSGCM patients had retroperitoneal bleeding. Differences in bleeding site distribution were not significant (p = 0.655). Packing involved one quadrant in 19 patients (65.5%), two in 6 (20.7%), three in 3 (10.3%), and four in 1 (3.4%). In the traditional group, packing was applied to one quadrant in 60%, two in 24%, three in 12%, and four in 4%. All ERFSGCM patients had single-quadrant packing. No significant difference was observed between groups (p = 0.486). Median preoperative INR was 1.3 (1.10–1.65) overall, 1.3 (1.08–1.62) in the traditional group, and 1.5 (1.33–1.75) in the ERFSGCM group, with no significant difference (p = 0.227). The median intraoperative blood loss (L) was 1.7 (1.2–3.0) for all patients, 1.8 (1.1–3.0) for patients undergoing traditional packing, and 1.5 (1.2–1.6) for patients undergoing packing using the ERFSGCM. There was no significant difference among the groups in terms of intraoperative blood loss (p = 0.444). The median intraoperative red blood cell suspension replacement (units) was 4 (2.5–4.5) for all patients, 4 (2–5) for patients undergoing traditional packing, and 4 (3.3–4.0) for patients undergoing packing using the ERFSGCM. The median intraoperative fresh frozen plasma replacement (L) was 2 (2–3) for all patients, 2 (1.5–4.0) for patients undergoing traditional packing, and 2 (2–2) for patients undergoing packing using the ERFSGCM. The median total blood/blood product replacement (units) was 6 (4.5–7.5) for all patients, 6 (4–8) for patients undergoing traditional packing, and 6 (5.3–6.0) for patients undergoing packing using the ERFSGCM. There were no significant differences between the groups regarding intraoperative replacements (p = 0.879, p = 0.927, p = 0.831). The median number of recurrent active bleeding episodes was 1 (0–1) for all patients, 1 (0–1) for patients undergoing traditional packing, and 0 (0–0) for those undergoing packing using the ERFSGCM. The number of recurrent active bleeding episodes was significantly lower in the ERFSGCM group (p = 0.043). The median number of surgeries during admission was 2 (1–3) overall, 2 (1.5–3.5) in the traditional group, and 1 (1–1) in the ERFSGCM group, significantly lower in the latter (p = 0.013). Initial abdominal closure methods included skin suturing in 15 patients (51.7%), a Bogota bag in 1 (3.4%), and both fascia and skin suturing in 13 (44.8%). In the traditional group, closure was achieved by skin suturing in 60%, a Bogota bag in 4%, and fascia plus skin suturing in 36%. All ERFSGCM patients underwent fascia and skin closure. Differences between groups were not statistically significant (p = 0.058). Postoperative acute renal failure was observed in a total of 15 patients (51.7%). Postoperative acute renal failure was observed in 15 patients (60%) in the traditional packing group, whereas none of the patients in the ERFSGCM group experienced such a complication. Postoperative acute renal failure was significantly less common in the ERFSGCM group (p = 0.042). Postoperative ischemic complications were identified in a total of 5 patients (17.9%). Postoperative ischemic complications were observed in 5 patients (20.8%) in the traditional packing group, whereas none were reported in the ERFSGCM group. No significant difference was found between the groups in terms of postoperative ischemic complications (p=1.000). Postoperative respiratory distress occurred in 11 patients (37.9%), all from the traditional packing group (44%). No cases were observed in the ERFSGCM group, and the difference was not statistically significant (p = 0.268). Anterior abdominal wall fascia was closed in 13 patients (44.8%): 9 (36%) in the traditional group and all in the ERFSGCM group, with significantly higher success in the latter (p = 0.030). Sixteen patients (55.2%) were discharged or died with an open fascia, all from the traditional group (64%). Final fascial closure was achieved during the initial surgery in 10 patients (34.5%): 6 (24%) in the traditional group and all in the ERFSGCM group. In the traditional group, closure occurred on postoperative days 1, 5, and 7 in one patient each (4%). No significant difference was observed between groups regarding the timing of closure (p = 0.066). Postoperative intra-abdominal abscesses occurred in 3 patients (10.3%), all from the traditional group (12%), with none in the ERFSGCM group (p = 1.000). Similarly, wound site infections were observed in 3 patients (10.3%), all in the traditional group (12%), with none in the ERFSGCM group (p = 1.000). Median mechanical ventilation was 2 days (1–4.5) overall, 2 (1–5.5) in the traditional group, and 1 (1–1) in the ERFSGCM group, with no significant difference (p = 0.181). Median ICU stay was 5 days (4–7.5) overall, 5 (3–8) in the traditional group, and 4.5 (4–5.8) in the ERFSGCM group (p = 0.647). Median hospital stay was 16 days (7–41) overall, 20 (6.5–43.5) in the traditional group, and 15.5 (10.5–16.8) in the ERFSGCM group, with no significant difference (p = 0.647). Clavien-Dindo scores were 2 in 4 patients (13.8%), 3 in 3 (10.3%), 4 in 4 (13.8%), and 5 in 18 (72%). In the traditional group, no patient scored 2; instead, 3 (12%) scored 3, 4 (16%) scored 4, and 18 (72%) scored 5. All ERFSGCM patients had a score of 2. The difference between groups was significant (p < 0.001). Mortality occurred in 18 patients (62.1%), all from the traditional group (72%), while none was observed in the ERFSGCM group, representing a significant difference (p = 0.014).
Discussion
Packing is a standard technique in the initial phase of damage control surgery to achieve rapid hemostasis. It is applied in massive hemorrhage when intervention time is limited, aiming to control bleeding through continuous pressure with gauze or compresses. Reported efficacy exceeds 90% [12].
Although indications for packing are well defined, the optimal timing for unpacking remains uncertain. The timing of re-laparotomy is critical for outcomes, yet no gold standard exists. Most studies recommend unpacking within 24–48 hours [13], while in high-grade liver injuries, delaying beyond 48 hours may reduce rebleeding risk. However, prolonged intervals increase infection risk and may hinder successful fascial closure [14]. Pommerening et al. recommended re-laparotomy within 24–48 hours, noting that delays may hinder fascial closure [15]. Abikhaled et al. reported increased infection and abscess risk when packing materials remained beyond 72 hours [16]. Thus, early unpacking has been emphasized, although Nicol et al. found prolonged packing was not associated with higher infection risk [17]. All patients underwent unpacking at 48 hours. Wound infection and abscess occurred in three patients (12%) in the traditional group, while none were observed in the ERFSGCM group. The difference was not statistically significant (p = 1.000 for both).
The primary goal of packing is hemostasis, with the absence of recurrent bleeding serving as a key success indicator [2,8,10]. In our study, recurrent bleeding occurred in one patient from the traditional group, while none was observed in the ERFSGCM group. The difference was statistically significant (p = 0.043).
Traditional packing requires a second-look re-laparotomy for unpacking, adding physiological stress and potential complications [18]. ERFSGCM eliminates this need, offering a significant advantage. In our study, the ERFSGCM group underwent fewer surgeries during hospitalization (p = 0.013), supporting its theoretical benefits. Moreover, ERFSGCM enables definitive fascial closure during the initial procedure, whereas multiple surgeries in the traditional method may hinder successful closure [19,20]. In some patients undergoing packing, excessive tension prevents abdominal wall closure. In such cases, temporary closure techniques or planned open management methods, including negative pressure wound
therapy or the Bogota bag, are commonly used [21]. In the ERFSGCM group, fascial closure was achieved in all patients, whereas some in the traditional group required alternative methods. Statistical analysis showed a significant difference between groups (p = 0.030). In cases without fascial closure, only skin suturing or the Bogota bag technique was used.
Our findings suggest that ERFSGCM facilitates definitive fascial closure more effectively than traditional packing. Although the absence of re-laparotomy may raise concerns regarding intra-abdominal hypertension or compartment syndrome, the technique’s design allows gradual withdrawal of the folded gauze, enabling controlled decompression. This feature represents its greatest advantage over the traditional method.
Postoperative acute renal failure was significantly less frequent in the ERFSGCM group (p = 0.042). Clavien-Dindo scores (p < 0.001) and mortality (p = 0.014) were also significantly lower, with ERFSGCM further associated with fewer overall complications.
Our findings suggest that ERFSGCM is at least as safe and effective as traditional packing, with evidence of superior outcomes. By eliminating the need for re-laparotomy and reducing the number of surgeries, ERFSGCM also demonstrates greater cost-effectiveness compared to the traditional method.
Limitations
Although our hospital is not a specialized trauma center, it serves as one of the key facilities in our region for the admission and treatment of emergency trauma patients. Despite this fact, the small sample size in our study poses a limitation in terms of statistical analysis. Although the patient sample size in our study is relatively small, its pioneering nature makes it a significant contribution to the literature.
Conclusion
The use of ERFSGCM as an alternative to the traditional packing method in patients with massive intra-abdominal hemorrhage can eliminate the need for re-laparotomy for unpacking. Furthermore, based on the results of our study, ERFSGCM demonstrates a more favorable profile regarding postoperative complications and mortality compared to traditional packing. However, further studies with larger patient populations are needed to establish the superiority of the ERFSGCM.
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, and 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.
References
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2. Marsden M, Carden R, Navaratne L, et al. Outcomes following trauma laparotomy for hypotensive trauma patients: a UK military and civilian perspective. J Trauma Acute Care Surg. 2018;85(3):620–5.
3. Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63(6):1338–47.
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6. Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420–5.
7. Klingensmith ME, Chen LE, Glasgow SC, et al. The Washington Manual of Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2008.
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9. Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock. 2011;4(1):114–9.
10. Jakob DA, Liasidis P, Schellenberg M, et al. Intra-abdominal hemorrhage control: the need for routine four-quadrant packing explored. World J Surg. 2021;45(4):1014–20.
11. Kim JM, Kim CW, Hong SK, et al. Intra-abdominal gauze packing for uncontrolled hemorrhage in non-trauma patients. J Acute Care Surg. 2021;11(2):64–70.
12. Mejia D, Warr SP, Delgado-López CA, et al. Reinterventions after damage control surgery. Colomb Med (Cali). 2021;52(2):e4154805.
13. Coccolini F, Roberts D, Ansaloni L, et al. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg. 2018;13:7.
14. Kang BH, Jung K, Choi D, et al. Early re-laparotomy for patients with high-grade liver injury after damage-control surgery and perihepatic packing. Surg Today. 2021;51(6):891–6.
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16. Abikhaled JA, Granchi TS, Wall MJ, et al. Prolonged abdominal packing for trauma is associated with increased morbidity and mortality. Am Surg. 1997;63(12):1109–13.
17. Nicol AJ, Hommes M, Primrose R, et al. Packing for control of hemorrhage in major liver trauma. World J Surg. 2007;31(3):569–74.
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19. Huang Q, Li J, Lau WY. Techniques for abdominal wall closure after damage control laparotomy: from temporary abdominal closure to early/delayed fascial closure—a review. Gastroenterol Res Pract. 2016;2016:2073260.
20. Hu P, Uhlich R, Gleason F, et al. Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis. World J Emerg Surg. 2018;13:43.
21. Quyn AJ, Johnston C, Hall D, et al. The open abdomen and temporary abdominal closure systems—historical evolution and systematic review. Colorectal Dis. 2012;14(8):e429–38.
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Göksever Akpınar, Batuhan Eyduran. Removable folded sterile gauze compression. Ann Clin Anal Med 2025;16(Suppl 3):S196-201
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Evaluation of clinical and laboratory parameters in adults investigated for suspected septic arthritis of the knee
Arman Vahabi 1, Merve Mert Vahabi 2, Mesut Demirkoparan 1, Hüseyin Aytaç Erdem 2, Elcil Kaya Biçer 1, Gözde Akkuş Kayalı 3, Şöhret Aydemir 3, Meltem Taşbakan 2, Semih Aydoğdu 1
1 Department of Orthopaedics and Traumatology, School of Medicine, Ege University, Izmir, Türkiye, 2 Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Ege University, Izmir, Türkiye, 3 Department of Clinical Microbiology, School of Medicine, Ege University, Izmir, Türkiye
DOI: 10.4328/ACAM.22927 Received: 2025-10-01 Accepted: 2025-10-24 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S202-205
Corresponding Author: Arman Vahabi, Department of Orthopaedics and Traumatology, School of Medicine, Ege University, Izmir, Türkiye. E-mail: armanvy@gmail.com P: +90 530 876 03 31 Corresponding Author ORCID ID: https://orcid.org/0000-0002-8937-6658
Other Authors ORCID ID: Merve Mert Vahabi, https://orcid.org/0000-0002-5008-0139 . Mesut Demirkoparan, https://orcid.org/0000-0002-5503-916X . Hüseyin Aytaç Erdem, https://orcid.org/0000-0001-7375-977X . Elcil Kaya Biçer, https://orcid.org/0000-0002-3315-6920 . Gözde Akkuş Kayalı, https://orcid.org/0000-0002-5776-4277 Şöhret Aydemir, https://orcid.org/0000-0001-8073-137X . Meltem Taşbakan, https://orcid.org/0000-0002-4689-720X . Semih Aydoğdu, https://orcid.org/0000-0002-2149-3225
This study was approved by the Ethics Committee of Ege University (Date: 2025-09-18, No: 25-9.1T/13)
Aim: Septic arthritis among adults most commonly affects the knee, hip, and shoulder joints, and is often treated with urgent surgical intervention. Although certain laboratory findings are considered definitive for diagnosis, a broad range of clinical and laboratory parameters can be observed. In this study, we evaluated the clinical and laboratory characteristics of adult patients who underwent joint aspiration with a preliminary diagnosis of septic arthritis.
Materials and Methods: A retrospective chart review was conducted to identify patients who underwent knee joint arthrocentesis for suspected septic arthritis between January 2020 and March 2024. Demographic data, synovial fluid analyses, laboratory parameters, physical examination findings, empirically initiated and culture-guided antibiotic treatments were recorded.
Results: Total of 159 patients included. Of those, 81 (50.9%) were male and 78 (49.1%) were female. Median age was 58 years (range 18-88). Mean WBC count was 10,366/mL (SD+ 4051.1), and the mean CRP was 106.84 mg/L (SD +87.2). 71 (44.6%) were clinically diagnosed with septic arthritis. Positive cultures were obtained in 36 patients. The most frequently isolated organisms were Staphylococcus aureus (n=20). Among the physical examination findings, pain was the most frequently observed, present in 92 of 159 patients (57.8%). Swelling was the second most common finding, identified in 90 patients (56.6%), followed by limitation of movement in 68 patients (42.7%).
Discussion: Septic arthritis of the knee may present with a wide spectrum of clinical and laboratory findings. Diagnosis should rely on the synthesis of these parameters and remain essentially clinical, rather than being based on a single variable.
Keywords: septic arthritis, infection, diagnostic criteria
Introduction
The annual incidence of septic arthritis is estimated at 2 to 10 cases per 100,000. Its pathogenesis includes hematogenous spread, direct inoculation, contiguous extension from adjacent infections, and iatrogenic causes1. A critical aspect of clinical practice is distinguishing septic arthritis from conditions such as gout, pseudogout, rheumatoid arthritis, and tumors, which can mimic its classic presentation [2-4]. The typical findings, including a red, warm, swollen knee with painful restriction of motion, are not unique to septic arthritis. Therefore, accurate differentiation is essential for timely and effective treatment.
Septic arthritis of the knee requires urgent surgical intervention combined with culture-specific antibiotic therapy. While most studies on septic arthritis focus on prognostic markers, diagnostic criteria, or uncommon pathogens, presenting updated epidemiological data and identifying local pathogens along with resistance patterns remain highly valuable. Such information could support timely empirical treatment, improve the likelihood of successful outcomes, and help prevent permanent sequelae [5-9].
The most valuable diagnostic tools for knee septic arthritis are white blood cell (WBC) counts, Gram staining, and cultures obtained through joint aspiration [1,10-12]. Typical cases present with clinical findings such as erythema, warmth, pain, and inability to bear weight, along with elevated WBC counts in synovial fluid and increased serum WBC, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels [7,10,13-15].
Materials and Methods
A retrospective chart review was conducted to identify patients who underwent knee joint arthrocentesis for suspected septic arthritis and were evaluated at the Infectious Diseases and Orthopedics Clinic between January 2020 and March 2024. Inclusion criteria were consultation with an infectious disease and/or orthopaedic clinic during the specified period due to suspicion of septic arthritis; being over 18 years of age; and requiring arthrocentesis in a case assessed for suspected septic arthritis. Exclusion criteria included cases younger than 18 years of age, patients with knee replacements, patients consulted with suspicion of septic arthritis due to involvement of joints other than the knee joint, patients with previously diagnosed rheumatoid arthritis, patients with recently performed knee surgery, patients undergoing arthrocentesis for reasons other than suspected septic arthritis, and patients with incomplete laboratory and clinical documentation.
Demographic variables, including age, sex, and the side of the affected joint, were recorded. For each patient, the results of direct microscopic examination and culture-antibiogram analyses of synovial fluid obtained during diagnostic arthrocentesis were documented. Concurrent laboratory parameters, including CRP levels and WBC counts, were recorded at the time of fluid sampling.
In addition, physical examination findings at the time of joint aspiration, empirically initiated antibiotic regimens, subsequent modifications based on culture susceptibility results, and duration of hospital stay were reviewed and included in the analysis.
Statistical analyses were performed using SPSS version 24. Numerical variables were expressed as mean ± standard deviation when normally distributed and as median (range) when not normally distributed. Categorical variables were summarized as frequencies and percentages. No comparative statistical analyses were conducted.
Ethical Approval
This study was approved by the ethics committee of Ege University (Date: 2025-09-18, No: 25-9.1T/13).
Results
The total number of patients included in the analysis was 159. Of the patients, 81 (50.9%) were male and 78 (49.1%) were female. The median age was 58 years (range 18-88).
The mean WBC count was 10,366/mL (SD + 4051.1), and the mean CRP was 106.84 mg/L (SD + 87.2). Of the 159 patients, 71 (44.6%) were clinically diagnosed with septic arthritis, while the diagnosis was excluded in the remaining 88 patients. Positive cultures were obtained in 36 patients, all of whom were among the clinically diagnosed septic arthritis. Thus, the culture positivity rate among clinically diagnosed cases was 36/71 (50.7%). The most frequently isolated organisms were Staphylococcus aureus (n = 20), Salmonella enterica ssp. enterica (n=3), Streptococcus dysgalactiae ssp. dysgalactiae (n = 2), Corynebacterium striatum (n = 2), and Stenotrophomonas maltophilia (n=2). Methicillin resistance was identified in one of the 20 patients with S. aureus, whereas the remaining 19 were methicillin sensitive (Table 1).
Regarding leukocyte counts in the synovial fluid of the 159 patients, 27 patients (16.9%) had counts >50,000, with culture growth observed in 7 of these cases. Thirty-four patients (21.4%) had leukocyte counts between 25,000 and 50,000, of whom 15 showed culture growth. The remaining 98 patients (61.6%) had leukocyte counts <25,000, and culture growth was detected in 14 of these cases.
Among the physical examination findings, pain was the most frequently observed, present in 92 of 159 patients (57.8%). Swelling was the second most common finding, identified in 90 patients (56.6%), followed by limitation of movement in 68 patients (42.7%). Increased local temperature was documented in 58 patients (36.4%), while hyperemia was observed in 25 patients (15.7%). Among the 71 patients clinically diagnosed with septic arthritis, empirical antibiotic treatment consisted of ampicillin–sulbactam in 21 patients and ceftriaxone–teicoplanin in 24 patients. In this group, the mean CRP level was 125.8 mg/L (Range: 4–393) and the mean WBC count was 10,762/mL (Range: 3,610–23,000).
Discussion
The most notable finding of this study is the presentation of current demographic, laboratory, and microbiological characteristics of patients initially diagnosed with septic arthritis of the knee at a tertiary referral hospital in western Turkey. Patients who were evaluated and treated for the diagnosis of septic arthritis demonstrated a broad spectrum of blood parameters, clinical examination findings, and synovial fluid analysis.
Among the 71 patients clinically diagnosed with septic arthritis, empirical antibiotic therapy consisted of ampicillin–sulbactam in 21 cases and ceftriaxone–teicoplanin in 24 cases. These regimens were initiated despite the fact that international guidelines recommend broader MRSA coverage. In Turkey, where MRSA prevalence is relatively low, ampicillin–sulbactam is considered a valid choice for methicillin-sensitive gram-positive infections, although national/local data is lacking [16]. Furthermore, while guidelines suggest ceftriaxone plus vancomycin, the nephrotoxic potential of vancomycin led to the preference for teicoplanin, which provides similar clinical efficacy with a more favorable safety profile. We believe that presenting local data in this context is therefore considered valuable to guide possible future practices.
While synovial fluid WBC counts exceeding 50,000 are often considered diagnostic for septic arthritis, septic arthritis can present across a broad clinical spectrum [17,18]. Because delayed or missed diagnosis may lead to severe morbidity due to joint destruction, the threshold for further testing and initiation of treatment should remain low, particularly in high-risk groups. It must also be emphasized that septic arthritis remains primarily a clinical diagnosis [5,15,17].
Although a leukocyte count of 50,000 in synovial fluid is generally considered the diagnostic cutoff, this parameter alone may be insufficient for accurate diagnosis [1,10-12]. In our study, counts below 25,000 were observed in patients with both clinical suspicion of septic arthritis and positive culture results. A considerable number of patients were also diagnosed clinically despite negative cultures. These findings indicate that the diagnosis of septic arthritis requires careful integration of clinical, laboratory, and microbiological data, rather than reliance on a single parameter.
Limitations
The main limitation of this study was the absence of a standardized, quantitative diagnostic algorithm for determining cases of septic arthritis included in the analysis. This limitation reduces reproducibility but reflects the inherent clinical challenges underlying the study design. Another limitation was the potential selection bias in the choice of empirical antibiotic regimens. However, since clinical outcomes were not presented or analyzed, we consider this limitation to have minimal impact on the validity of the reported results.
Conclusion
Septic arthritis of the knee may present with a wide spectrum of clinical and laboratory findings. Diagnosis should rely on the synthesis of these parameters and remain essentially clinical, rather than being based on a single variable.
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, and 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.
References
1. Elsissy JG, Liu JN, Wilton PJ, Nwachuku I, Gowd AK, Amin NH. Bacterial Septic Arthritis of the Adult Native Knee Joint: A Review. JBJS Rev. 2020;8(1):1-10.
2. Indra F, Anuar-Ramdhan IM, Vick-Duin E, Awang-Ojep DN. Pigmented villonodular synovitis (PVNS) of the knee mimicking septic arthritis in a paediatric patient: A Case Report. Malays Orthop J. 2021;15(3):122-6.
3. Thavasianantham K, Raagul T, Ganesh A, Elangovan P, P H, Regunathan PS. Unusual presentation of synovial lipomatosis mimicking as septic arthritis of knee: A case report. Cureus. 2024;16(4):1-5.
4. Soule SM, Huntsman A, Chandra S, Thorne T, Holmes S, McKinley K. Inflammatory knee reaction mimicking septic arthritis following closely spaced pneumococcal vaccines in a pediatric patient undergoing immunodeficiency evaluation. Cureus. 2025;17(6):1-5.
5. Böhle S, Finsterbusch L, Kirschberg J, et al. Incidence of secondary osteoarthritis after primary shoulder and knee empyema and its risk factors. J Pers Med. 2024;14(3):1-13.
6. Clement RGE, Wong SJ, Hall A, Howie SEM, Simpson AHRW. The long-term time course of septic arthritis. Bone Jt Open. 2024;5(9):785-92.
7. Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. The Lancet. 2010;375(9717):846-55.
8. Ferrand J, El Samad Y, Brunschweiler B, et al. Morbimortality in adult patients with septic arthritis: a three-year hospital-based study. BMC Infect Dis. 2016;16(1):1-10.
9. Baysal NB, Emecen AN, Arslan F, Vahaboğlu H. Methicillin-resistant staphylococcus aureus septic arthritis: A case report with the possible colchicine effect to the bacterial persistence. Mediterr J Infect Microb Antimicrob. 2019;8:1-3.
10. Holzmeister A, Frazzetta J, Yuan FFN, et al. Evaluation for septic arthritis of the native adult knee is aided by multivariable assessment. Am J Emerg Med. 2021;46:614-8.
11. Alexandersson H, Dehlin M, Jin T. Validation of septic arthritis diagnosis and disease characteristics in West Sweden. Infect Dis (Lond). 2025;57(9):850-60.
12. Eren TK, Aktekin CN. How reliable are the synovial cell count and blood parameters in the diagnosis of septic arthritis? Jt Dis Relat Surg. 2023;34(3):724-30.
13. Gunay H, Bakan OM, Mirzazade J, Sozbilen MC. A New perspective on the diagnosis of septic arthritis: High-resolution thermal imaging. J Clin Med. 2023;12(4):1-13.
14. Bayram S, Bilgili F, Kıral D, Yağcı TF, Yıldırım AM, Demirel M. Which inflammatory marker is more reliable in diagnosing acute septic arthritis in the pediatric population? Pediatr Int. 2021;63(8):889-94.
15. Tverring J, Johansson A, Bornaei O, Lantz A, Ljungquist O. Septic arthritis score (SAS) – a novel clinical prediction model for the probability of septic arthritis in the adult native knee. BMC Infect Dis. 2025;25(1):1-9.
16. Duran H, Çeken N, Kula Atik T. Çeşitli Klinik Örneklerden İzole Edilen Staphylococcus aureus Suşlarının Antibiyotik Direnç Oranları [Antibiotic Resistance Rates of Staphylococcus aureus Strains Isolated from Various Clinical Samples]. Turk Mikrobiyol Cemiy Derg. 2021;51(3):233-8.
17. Sanpera I, Salom M, Alves C, Eastwood D. Diagnosis and management of septic arthritis: A current concepts review. J Child Orthop. 2025;19(1):14-9.
18. Morgan AM, Ferati S, Fong C, Egol K. Identifying septic arthritis superimposed on crystalline arthropathy: Is synovial cell count the answer? J Clin Orthop Trauma. 2025;65:1-6.
Download attachments: 10.4328.ACAM.22927
Arman Vahabi, Merve Mert Vahabi, Mesut Demirkoparan, Hüseyin Aytaç Erdem, Elcil Kaya Biçer, Gözde Akkuş Kayalı, Şöhret Aydemir, Meltem Taşbakan, Semih Aydoğdu. Evaluation of clinical and laboratory parameters in adults investigated for suspected septic arthritis of the knee. Ann Clin Anal Med 2025;16(Suppl 3):S202-205
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Low-dose prostaglandin E1 usage in term newborns with duct-dependent congenital heart disease
Muhammet Hamza Halil Toprak, Erkut Öztürk
Department of Pediatric Cardiology, University of Health Sciences, Basaksehir Cam and Sakura Hospital, Istanbul, Turkey
DOI: 10.4328/ACAM.22928 Received: 2025-10-01 Accepted: 2025-10-23 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S206-210
Corresponding Author: Muhammet Hamza Halil Toprak, Department of Pediatric Cardiology, University of Health Sciences, Basaksehir Cam and Sakura Hospital, Istanbul, Turkey. E-mail: muhammedhamzatoprak@hotmail.com P: +90 212 909 60 00 Corresponding Author ORCID ID: https://orcid.org/0000-0003-4579-963X
Other Authors ORCID ID: Erkut Ozturk, https://orcid.org/0000-0002-1762-3269
This study was approved by the Ethics Committee of Başakşehir Çam ve Sakura City Hospital (Date: 2025-08-08, No: 316)
Aim: This study aimed to investigate the usage and effects of low-dose Prostaglandin E1 in term newborns diagnosed with duct-dependent congenital heart disease.
Materials and Methods: The study was conducted retrospectively on term cases diagnosed with duct-dependent congenital heart disease monitored in the pediatric cardiac intensive care unit between January 1, 2022, and January 1, 2024. The usage and effects of low-dose Prostaglandin E1 applied according to our clinical protocol were evaluated in the cases. The results were analyzed statistically.
Results: There were 235 cases (57% male) during the study period. The median weight was 2950 grams (IQR 2800-3100 grams), and the median gestational age was 39 weeks (IQR 38-40 weeks). There were systemic-dependent CHD (n = 91), pulmonary-dependent CHD (n = 102), and mixing CHD (n = 42) cases. The median duration of PGE1 usage was 6 days (IQR 5-7 days). While the maintenance dose according to our clinical protocol was 0.005, dose escalation was observed in 20/91 (22%) systemic-dependent cases, 14/102 (13.7%) pulmonary-dependent cases, and 4/42 (9.5%) mixing cases (p< 0.05). Edema was observed in 38 cases (16.1%), hyperthermia in 31 cases (13.1%), gastrointestinal problems in 31 cases (13.1%), and apnea in 17 cases (7.2%).
Discussion: Low-dose PGE1 usage in term newborns diagnosed with duct-dependent congenital heart disease has been effective in maintaining duct patency. The usage of low-dose PGE1 resulted in a decrease in adverse effects compared to the reported rates in the literature.
Keywords: newborn, congenital heart disease, prostaglandin E1
Introduction
Congenital heart disease (CHD) has a prevalence ranging from 4 to 8 per 1000 live births and represents a significant health issue for term infants. Critical CHD is a major cause of low cardiac output requiring surgical or catheter intervention within the first year of life, comprising approximately 15-25% of infants with CHD [1].
Duct-dependent congenital heart disease (DD-CHD) consists of cardiac lesions requiring a patent ductus arteriosus (PDA) for pulmonary or systemic blood flow. Infants with DD-CHD may develop cyanosis/hypoxia or decreased perfusion within hours or days after birth due to the closure of the PDA [2]. Based on their anatomical features and treatment approach, DD-CHD infants are categorized into three distinct groups: those dependent on systemic blood flow (such as aortic stenosis, interrupted aortic arch, hypoplastic left heart syndrome), those dependent on pulmonary blood flow (including pulmonary atresia, Tetralogy of Fallot, critical pulmonary stenosis, Ebstein anomaly), and those requiring adequate mixing (such as transposition of the great arteries) [1,3].
Prostaglandin E1 therapy is a well-known effective method for maintaining ductal patency in term infants with duct-dependent congenital heart disease (DD-CHD). In patients with DD-CHD, the administration of prostaglandin E1 (PGE1) helps preserve medical palliative shunting until an interventional procedure can be performed. However, prostaglandin E1 therapy poses specific challenges in the management of these patients. Apnea, hypoventilation, hypotension, vasodilation, flushing, diarrhea, seizures, and hyperpyrexia have been reported as common side effects of short-term, standard-dose prostaglandin E1 therapy [4-6].
The original dosage recommendation for Prostaglandin E1 was initially in the range of 0.05-0.10 μg/kg/minute, with subsequent reduction of the maintenance dose to 0.025 μg/kg/minute. Since the official approval of Prostaglandin E1, several studies have investigated the effectiveness of lower maintenance dose regimens. However, it is not yet clear how low the dose can be while maintaining ductal patency or how low it should be to minimize side effects [7].
In this study, we aimed to evaluate the effectiveness and side effect profile of Prostaglandin E1 at the starting dose of 0.01 μg/kg/minute and maintenance dose of 0.003-0.005 μg/kg/minute, which is our institutional protocol that has been implemented for a long time.
Materials and Methods
This study was conducted retrospectively on term cases diagnosed with duct-dependent congenital heart disease and followed in the pediatric cardiac intensive care unit between January 1, 2022, and January 1, 2024. In accordance with our clinical practice, Prostaglandin E1 was administered at a starting dose of 0.01 μg/kg/minute and a maintenance dose of 0.003-0.005 μg/kg/minute.
Patients with critical CHD who started prostaglandin E1 intake after the age of fourteen days, received prostaglandin E1 for more than 24 hours at another center, had a total dose duration of less than 12 hours, were born with a closed ductus arteriosus, and were diagnosed with heterotaxy syndrome, as well as those with severe neurological disorders such as trisomy 13 and 18, were excluded from the study. The study was planned in accordance with the Helsinki Declaration after obtaining approval from the local committee.
Gestational age of 37 weeks or more was defined as full-term. Newborns with ductal dependent-CHD were grouped into three categories: (i) duct dependent pulmonary circulation (e.g., pulmonary atresia and tetralogy of Fallot), (ii)duct dependent systemic circulation (e.g., hypoplastic left heart syndrome, coarctation of aorta, and interruption of the aortic arch), (iii) duct dependent without an adequate mixing of blood between the two circulations (e.g., transposition of the great arteries) [3]. Echocardiograms, surgical, and catheterization reports were utilized to establish the final diagnosis and categorize patients into groups.
Demographic and clinical data were collected from medical records. Patient demographic data were collected, including gestational age, birth weight, diagnosis of CHD, and prenatal diagnosis. The total duration and dosage of PGE1 administration were recorded. Adverse effects were divided into groups as follows [8].
-Gastrointestinal: feeding intolerance (gastrointestinal reflux, vomiting, and residues over 25% of feed), number of feeding cessations during the infants’ hospital stay, necrotizing enterocolitis (NEC, stage 2 and over according to Bell’s criteria, diarrhea, and gastric antral mucosal hypertrophy [9].
-Cardiovascular: edema, flushing, heart failure, arrhythmia, bradycardia < 100 bpm, tachycardia > 180 bpm, and hypotension requiring medical treatment.
– Miscellaneous: hyperthermia (defined as body temperature > 37.5 °C, apnea, bleeding, seizure, jitteriness.
The data were analyzed using SPSS Statistics 21. The demographic data were presented as the number, percentage, and median (interquartile range (IQR)). Differences among categorical variables were tested via Pearson’s chi-squared or Fisher’s exact test. Differences among means between normally distributed continuous variables were evaluated with Student’s t-test or analysis of variance. Differences among medians between continuous variables with non-parametric distribution were evaluated with the Mann-Whitney U-test or Kruskal–Wallis test. Both univariate and multivariate logistic regression were utilised to compare predictor variables with dichotomous categorical outcome variables. P values of <.05 were considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Basaksehir Cam ve Sakura City Hospital (Date: 2025-08-08, No: 316).
Results
During the study period, there were 235 cases (57% male) available. Of these, 91 cases had systemic-dependent CHD, 102 cases had pulmonary-dependent CHD, and 42 cases had mixing CHD. The specific CHD diagnoses and general characteristics of the cases are shown in Table 1.
The median weight was 2950 grams (IQR 2800-3100 grams), and the median gestational age was 39 weeks (IQR 38-40 weeks). The median duration of PGE1 usage was 6 days (IQR 5-7 days). While the maintenance dose according to our clinical protocol was 0.005, dose escalation was observed in 20 out of 91 systemic-dependent cases, 14 out of 102 pulmonary-dependent cases, and 4 out of 42 mixing cases (p< 0.05). The clinical and general characteristics of the cases are shown in Table 2. PGE1 usage continued for more than 30 days in three cases diagnosed with hypoplastic left heart syndrome.
A greater proportion of patients with systemic obstruction (20/91, 22%) required a dose increase than those with pulmonary obstruction (14/102, 13.7%, p = 0.03). Additionally, patients with dose escalation had significantly longer treatment times with prostaglandin E1, with a median of 225 hours compared with 127 hours for those without dose escalation (p =0.004). Univariate (p = 0.005, odds ratio 1.09, 95% confidence interval 1.006–1.012) and multivariate (p = 0.008, odds ratio 1.006, 95% confidence interval 1.004–1.008) logistic regression also identified a statistically significant association between dose escalation and each additional hour of prostaglandin E1 treatment.
Edema was observed in thirty-eight cases (16.1%), hyperthermia in thirty-one cases (13.1%), gastrointestinal issues in thirty-one cases (13.1%), and apnea in seventeen cases (7.2%). The observed side effects in the cases are summarized in Table 3.
Discussion
This study evaluated the use of low-dose prostaglandin E1 and its potential effects in term newborns diagnosed with duct-dependent congenital heart disease in the pediatric cardiac surgery intensive care unit of a high-volume cardiac center. We found that prostaglandin E1 can be used at low doses; dose escalation may be required more frequently in systemic-dependent DD-CHD cases, and observed side effects may occur less frequently compared to high-dose protocols. Our study contributes to the literature as one of the limited studies providing insights into these characteristics.
Prostaglandin E1 is recommended as a temporary initial treatment for infants with isolated defects that restrict pulmonary blood flow. This treatment is used in infants with conditions that limit arterial-venous mixing and impede systemic circulation. It ensures the patency of the ductus arteriosus and maintains pulmonary and systemic circulation and oxygenation until appropriate surgical intervention can take place [10]. The policy for administering PGE1 therapy to newborns with duct-dependent congenital heart disease includes a regimen with an initial dose of PGE1 at 0.03-0.05 μg/kg/minute. This regimen, proposed by Doblec, should be combined with early pediatric cardiology consultation, as it has been shown to improve outcomes [11].
Kramer et al. examined various doses in 91 patients and reported on the efficacy and side effect profile. The authors used different starting and maintenance doses. As a result, they recommended an initial dose of 0.015 μg/kg/minute, but noted that patients with systemic obstruction may require higher doses. Most of these patients initially received a prostaglandin E1 dose of 0.01 μg/kg/minute, and inadequate mixing was present in more than half of this cohort [12].
Vari et al. evaluated 154 cases of duct-dependent congenital heart disease. They found that Prostaglandin E1 at a starting and maintenance dose of 0.01 μg/kg/minute was sufficient to maintain ductal patency in 83% of our cohort. The incidence of respiratory depression requiring mechanical ventilation was low and was typically seen in premature infants. They stated that low-dose (0.01 μg/kg/minute) Prostaglandin E1 initiated for critical congenital heart disease is a safe and effective treatment. They also noted that the dose escalation in cases with pulmonary obstruction was higher compared to the systemic and mixing groups [7].
Yucel et al. provided evidence that maintenance doses as low as 0.003-0.005 could maintain ductal patency. However, in their cohort of 95 patients, they noted that all patients were initiated at doses of 0.03 μg/kg/minute or higher, with an average starting dose of 0.065 μg/kg/minute. The authors also concluded that lesions with systemic obstruction may require higher doses [13].
In our study, ductal patency was maintained in 84% of our cases at doses of 0.003-0.005, similar to findings by Yücel and colleagues. Similarly, patients with systemic obstruction required a significantly higher dose escalation.
PGE1 treatment may be accompanied by multiple adverse effects. Under the current dosage scheme, there are many reports regarding the side effects of PGE1, and it has been shown that side effects increase with higher doses. Cucerea et al. administered an initial dose of PGE1 at 0.06-0.15 μg/kg/minute by continuous infusion in their series of 66 cases.
During PGE1 treatment, eleven infants (16.7%) had apnea attacks, five infants (7.5%) had convulsions, thirty-three (50%) had a fever, and forty-seven (71.2%) had leukocytosis (more than 20.000/mm3), and fifty-two (78.8%) had edema. Other complications possibly related to PGE1 therapy were listed as 25.8% had gastrointestinal intolerance, 45.5% had hypokalemia, and 63.6% had irritability. Additional complications like ectropion, cardiac arrest, and antral hyperplasia were recorded in fewer than 5% of the neonates [14].
Shlomai et al. reported apnea in 20.7% of cases, edema in 18.3%, hyperthermia in 18.3%, and gastrointestinal symptoms in 13.4% in their series of 82 cases using PGE1 at a dose of 0.05 μg/kg/minute (6). Talosi et al. recorded a 42% rate of apnea with a 14% rate of intubation due to respiratory depression in their study of 49 cases at initial doses between 0.025 and 0.05 μg/kg/minute [15].
In the series by Vari and colleagues, respiratory problems were observed in 28% of cases at a continuous dose of 0.01 μg/kg/minute. In 10 of these patients, the respiratory depression was transient and did not merit initiation of respiratory support, although four were started on caffeine [7].
In our study, a significant decrease in the incidence of side effects was observed with the administration of low-dose PGE1 compared to high-dose applications.
Limitations
The main limitations of this study include its retrospective nature, single-center design, and the limited number of cases. Additionally, in cases of complete transposition of the great arteries with limited interatrial communication, maintaining ductal patency may be insufficient to ensure hemodynamic stability.
Conclusion
The use of low-dose PGE1 has been effective in maintaining ductal patency in term newborns diagnosed with duct-dependent congenital heart disease. A decrease in PGE1 side effects has been observed compared to the rates reported in the literature.
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, and 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.
References
1. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39(12):1890-900.
2. Akkinapally S, Hundalani SG, Kulkarni M, et al. Prostaglandin E1 for maintaining ductal patency in neonates with ductal-dependent cardiac lesions. Cochrane Database Syst Rev. 2018;2(2):114-7.
3. Khalil M, Jux C, Rueblinger L, Behrje J, Esmaeili A, Schranz D. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr. 2019;8(2):114-26.
4. Alhussin W, Verklan MT. Complications of long-term prostaglandin E1 use in newborns with ductal-dependent critical congenital heart disease. J Perinat Neonatal Nurs. 2016;30(1):73-9.
5. Freed MD, Heymann MA, Lewis AB, Roehl SL, Kensey RC. Prostaglandin E1 infants with ductus arteriosus-dependent congenital heart disease. Circulation 1981;64(5):899-905.
6. Singh Y, Mikrou P. Use of prostaglandins in duct-dependent congenital heart conditions. Arch Dis Child Educ Pract Ed. 2018;103(3):137-40.
7. Vari D, Xiao W, Behere S, Spurrier E, Tsuda T, Baffa JM. Low-dose prostaglandin E1 is safe and effective for critical congenital heart disease: is it time to revisit the dosing guidelines? Cardiol Young. 2021;31(1):63-70.
8. Ofek Shlomai N, Lazarovitz G, Koplewitz B, Eventov Friedman S. Cumulative dose of prostaglandin E1 determines gastrointestinal adverse effects in term and near-term neonates awaiting cardiac surgery: A retrospective cohort study. Children (Basel). 2023;10(9):1572.
9. Bell MJ, Ternberg JL, Feigin RD, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978;187(1):1-7.
10. Aykanat A, Yavuz T, Özalkaya E, Topçuoğlu S, Ovalı F, Karatekin G. Long-term prostaglandin E1 infusion for newborns with critical congenital heart disease. Pediatr Cardiol. 2016;37(1):131-4.
11. Dolbec K. Congenital heart disease. Emerg Med Clin North Am. 2011;29(4):811-27.
12. Kramer HH, Sommer M, Rammos S, Krogmann O. Evaluation of low dose prostaglandin E1 treatment for ductus dependent congenital heart disease.Eur J Pediatr 1995;154(9):700-7.
13. Yucel IK, Cevik A, Bulut MO, et al. Efficacy of very low-dose prostaglandin E1 in duct-dependent congenital heart disease. Cardiol. Young 2015;25(1):56-62.
14. Cucerea M, Simon M, Moldovan E, Ungureanu M, Marian R, Suciu L. Congenital heart disease requiring maintenance of ductus arteriosus in critically ill newborns admitted at a tertiary neonatal intensive care unit. J Crit Care Med (Targu Mures). 2016;2(4):185-91.
15. Talosi G, Katona M, Racz K, Kertesz E, Onozo B, Turi S. Prostaglandin E1 treatment in patent ductus arteriosus dependent congenital heart defects. J Perinat Med. 2004;32(4):368-74.
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Muhammet Hamza Halil Toprak, Erkut Öztürk, Low-dose prostaglandin E1 usage in term newborns with duct-dependent congenital heart disease. Ann Clin Anal Med 2025;16(Suppl 3):S206-210
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Prevalence of helicobacter pylori infection and its histopathological correlation in adult celiac patients
Ali Cagri Oral 1, Mehmet Yalnız 2, Furkan Kırsoy 2, Abdullah Mübin Özercan 2, Sedat Çiçek 2, İbrahim Halil Bahçecioğlu 2
1 Department of Gastroenterology, Elazığ Fethi Sekin City Hospital, Elazığ, Turkey, 2 Department of Gastroenterology, Fırat University Hospital, Elazığ, Turkey
DOI: 10.4328/ACAM.22930 Received: 2025-10-04 Accepted: 2025-10-23 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S211-214
Corresponding Author: Ali Cagri Oral, Department of Gastroenterology, Elazığ Fethi Sekin City Hospital, Elazığ, Turkey. E-mail: alioral.88@gmail.com P: +90 536 683 45 60 Corresponding Author ORCID ID: https://orcid.org/0000-0002-6551-7620
Other Authors ORCID ID: Mehmet Yalniz, https://orcid.org/0000-0001-7776-4154 . Furkan Kirsoy, https://orcid.org/0000-0002-9379-3286 . Abdullah Mübin Özercan, https://orcid.org/0000-0002-6968-7838 . Sedat Çiçek, https://orcid.org/0000-0003-0140-7796 . İbrahim Halil Bahçecioğlu https://orcid.org/0000-0001-9705-8281
This study was approved by the Ethics Committee of Firat University (Date: 2024-08-01, No: 2024/11-05)
Aim: Celiac disease (CD) is a chronic autoimmune enteropathy associated with gluten intake in genetically predisposed individuals. Helicobacter pylori (H. pylori) is a common gastric pathogen, and its relationship with CD remains unclear. This study aimed to investigate the prevalence of H. pylori infection and its histopathological effects in adult CD patients.
Material and Methods: This retrospective study includes patients diagnosed with CH at the Gastroenterology Clinic of Fırat University Hospital. Patients with a confirmed diagnosis of CH based on duodenal biopsy were included in the study. H. pylori status was determined by histological evaluation of gastric biopsies taken according to the Sidney protocol. Demographic, clinical, and histopathological data were obtained from patient files.
Results: A total of 216 CH patients were included in the study (174 [80.6%] H. pylori positive, 42 [19.4%] H. pylori negative). There were no significant differences in gender distribution and Marsh classification between the groups (p>0.05). Marsh 3A and 3B (31.6%) were the most common in H. pylori-positive cases, while Marsh 3B (38.1%) was the most common in H. pylori-negative cases. Chronic gastritis was observed at a high rate in both groups (positive 96%; negative 95.2%).
Discussion: Although H. pylori infection is common in patients with Crohn’s disease, no significant effect on histopathological findings and Marsh stages has been detected. Our findings indicate that the effect of H. pylori on Crohn’s disease remains controversial and therefore requires large-scale, multicenter prospective studies.
Keywords: celiac disease, helicobacter pylori, marsh classification, histopathology
Introduction
Celiac disease is a chronic disorder that may develop at any stage of life in genetically predisposed individuals following the consumption of gluten-containing foods. Also referred to as gluten enteropathy, it is an immune-mediated condition characterized by a T-cell–driven immune response to gluten. Affecting approximately 1% of the global population, celiac disease represents a major public health concern due to its relatively high prevalence and potential for serious complications [1-3]. Gluten-containing grains such as wheat, barley, and rye, as well as their derived products, trigger an abnormal immune reaction, resulting in both serological and histopathological alterations. These include the production of tissue transglutaminase, anti-gliadin, and anti-endomysial antibodies, as well as increased intraepithelial lymphocytes in the small intestinal mucosa, crypt hyperplasia, and villous atrophy. The importance of celiac disease has become increasingly recognized in recent decades, with current data indicating a prevalence of approximately 1.4% worldwide and a notable rise in incidence over the past forty years [4,5]. At present, the cornerstone of management remains strict adherence to a gluten-free diet, which is often difficult to sustain in practice and poses considerable social challenges [6].
Helicobacter pylori is a bacterium that colonizes the gastric mucosa and plays a well-established role in the pathogenesis of peptic ulcer disease, gastric carcinoma, and mucosa-associated lymphoid tissue (MALT) lymphoma [7]. However, its exact contribution to the etiology of dyspepsia, particularly functional dyspepsia, remains uncertain, as many infected patients fail to achieve symptom relief even after successful eradication therapy. This observation suggests the involvement of additional pathogenic mechanisms or host-related factors. Histological evaluation of gastric mucosa obtained through biopsy remains essential for detecting chronic inflammatory changes, atrophy, and other histopathological abnormalities that may not be visible on endoscopic examination alone [8-11].
Genetic and environmental factors are known to play a role in the etiopathogenesis of celiac disease, while comorbid gastrointestinal conditions may also influence its course and clinical presentation. Among these, Helicobacter pylori infection can induce mucosal changes that resemble those observed in celiac disease, potentially leading to clinical overlap between the two disorders. The present study aims to investigate the prevalence of H. pylori infection in patients with celiac disease and to evaluate its potential clinical impact, as well as possible interactions between the two conditions.
Materials and Methods
The study was approved by the Clinical Research Ethics Committee of Fırat University Faculty of Medicine (decision number 2024/11-05, dated 01.08.2024). The research protocol was carried out in accordance with the principles of the Declaration of Helsinki. This retrospective study was conducted at the Adult Gastroenterology Clinic of Fırat University Faculty of Medicine Hospital. Patients who had undergone upper gastrointestinal endoscopy for suspected celiac disease prior to 2024 and who demonstrated both positive histological findings and serological test results in duodenal biopsies were included in the study. Biopsy samples obtained from these patients for Helicobacter pylori evaluation, in accordance with the Sydney protocol, were also assessed. Data on patients’ sex, age, presenting symptoms, comorbidities, medication use, and biochemical parameters were recorded using standardized clinical data collection forms and retrieved retrospectively from patient files.
Statistical Analysis
Statistical analyses were performed using SPSS v. 22 (Statistical Package for the Social Sciences; SPSS Inc., Chicago, IL). The normality of the distribution of continuous variables was determined using the Kolmogorov-Smirnov test. The Kruskal-Wallis test was used for comparisons between more than two groups. Following the Kruskal-Wallis test, the Post Hoc Dunn test was used for pairwise group comparisons. The chi-square test and Fisher’s exact test were performed for categorical data analysis. Numerical data were expressed as Median (IQR), and categorical data as percentage (%). Spearman’s correlation test was performed to analyze correlations between continuous variables. Logistic regression analysis was used to calculate risk factors, starting with a univariate analysis, followed by a multivariate analysis for variables found to be significant in the first stage. Statistical significance was set at p < 0.05.
Ethical Approval
This study was approved by the Ethics Committee of Firat University (Date: 2024-08-01, No: 2024/11-05).
Results
Among the 216 patients with celiac disease included in the study, 174 (80.6%) were Helicobacter pylori–positive, while 42 (19.4%) were H. pylori–negative (Figure 1). The gender distribution did not differ significantly between the groups (H. pylori–positive: 114 women and 60 men; H. pylori–negative: 13 women and 29 men; p=0.664).
Histopathological examinations showed that edematous gastric changes were observed in only one H. pylori–negative patient (2.4%), a difference that was not statistically significant (p = 0.116). Chronic gastritis was detected in 96% of the H. pylori–positive group and 95.2% of the negative group. The rates of intestinal metaplasia were 4% and 2.4%, respectively, with no significant difference between the groups.
According to the MARSH classification, stages 3A (31.6%) and 3B (31.6%) were the most common in H. pylori–positive patients, while stage 3B (38.1%) predominated in H. pylori–negative patients. No statistically significant difference was found in stage distribution (p = 0.679).
In terms of clinical symptoms, dyspepsia was present in 81% of H. pylori–positive patients and 76.2% of negative patients (p = 0.480). Diarrhea was reported in 21.3% of H. pylori–positive patients compared with 35.7% of negative patients, a statistically significant difference (p = 0.049). Weight loss was observed in 10.3% of H. pylori–positive patients and 2.4% of negative patients, although this difference did not reach statistical significance (p = 0.082) (Table 1). In the study group, the Helicobacter pylori positivity rate was 80.56% and the negativity rate was 19.44%( figüre 1).
Discussion
According to our findings, although Helicobacter pylori infection is common among patients with celiac disease, it did not have a significant impact on histopathological findings or MARSH stage distribution. Nonetheless, the higher prevalence of diarrhea observed in H. pylori–negative patients suggests that the bacterium may exert an indirect influence on symptom severity.
The relationship between Helicobacter pylori infection and celiac disease has been investigated in numerous studies, yet the findings remain inconsistent [12-14]. For example, a large cross-sectional study by Lebwohl et al. demonstrated an inverse association between H. pylori and celiac disease, even after adjusting for sociodemographic factors, suggesting a possible protective role of the bacterium against celiac disease development [15]. In addition, studies from regions with a high prevalence of H. pylori, such as Latin America, have reported celiac disease prevalence rates comparable to those in European populations, implying that the presence of H. pylori may not be a decisive factor in disease pathogenesis [6,17]. Although H. pylori infection was common in our cohort, no significant association was observed. Taken together with previous evidence, these findings underscore the ongoing controversy regarding the role of H. pylori in celiac disease and highlight the need for larger, well-designed studies to clarify this relationship.
Histopathological examination remains the gold standard for the diagnosis of celiac disease, gastric lesions, and Helicobacter pylori infection [18]. Previous studies have reported that duodenal intraepithelial lymphocytes may increase in patients with H. pylori gastritis and that this finding can be reversed following eradication therapy. Other studies have shown that the clinicopathological features of celiac patients infected with H. pylori do not differ significantly from those without infection, and that both groups demonstrate a similar response to a gluten-free diet. Moreover, it has been suggested that while mild duodenal lesions and lymphocytosis triggered by gastritis are more frequent in H. pylori–infected celiac patients, these changes are associated with lower rates of deep inflammation and stricture compared to other mucosal alterations [19]. Some evidence also indicates that the increase in intraepithelial lymphocytes may, in certain cases, reflect an inappropriate host immune response to H. pylori. Consequently, it has been emphasized that screening for H. pylori infection and considering eradication therapy may be beneficial before initiating a gluten-free diet [20]. Therrien and colleagues reported a prevalence of chronic gastritis of 31.3% among patients with celiac disease [21]. Moreover, their observation of higher antibody titers in cases with gastritis—independent of the degree of villous atrophy—supports the lack of differences in MARSH stages, as the prevalence of chronic gastritis observed in our study was similarly high. In line with this, several studies have suggested that gastric pathologies may influence the duodenum and that Helicobacter pylori, after colonizing the gastric mucosa, can contribute to the development of duodenitis. Accordingly, it has been recommended that biopsies be obtained from both the stomach and duodenum in patients presenting with duodenal pathology [22]. Consistent with our results, some studies have also reported that H. pylori infection is less frequent in celiac patients, and that duodenal damage—as assessed by Marsh score—tends to decrease with increasing H. pylori density [13,23]. Villanacci et al. similarly observed milder villous atrophy in H. pylori–positive celiac patients, while another study found a higher prevalence of H. pylori in Marsh grade 1/2 lesions and a lower prevalence in Marsh grade 3 lesions [19,24]. These findings suggest that H. pylori may exert a protective effect by mitigating histopathological damage. However, a multicenter study by Bayrak et al. did not confirm this relationship, reporting no significant association between H. pylori infection and duodenal injury [25].
Limitations
This study has several limitations. First, it was conducted at a single center with a relatively small sample size. Second, due to its cross-sectional design, causal inferences regarding the relationship between Helicobacter pylori infection and celiac disease cannot be established, which limits the generalizability of the findings. Third, socioeconomic and environmental factors—both of which are known to influence H. pylori prevalence and celiac disease—could not be evaluated because of the retrospective nature of the study. Fourth, reliance solely on histopathological methods for the diagnosis of H. pylori precluded comparison with alternative diagnostic techniques. Finally, as data on symptom severity were obtained retrospectively from patient records, the potential for subjectivity and recall bias should be taken into account.
Conclusion
In conclusion, the combined evaluation of our results and previous evidence suggests that Helicobacter pylori infection does not exert a decisive influence on histopathological progression in patients with celiac disease. Nevertheless, the potential role of H. pylori in modulating symptom severity or attenuating histological damage remains controversial. Further large-scale, prospective studies are warranted to clarify this complex relationship.
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, and 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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25. Bayrak NA, Tutar E, Volkan B, et al. Helicobacter pylori infection in children with celiac disease: multi-center, cross-sectional study. Helicobacter. 2020;25(5):e12691.
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Ali Cagri Oral, Mehmet Yalnız, Furkan Kırsoy, Abdullah Mübin Özercan, Sedat Çiçek, İbrahim Halil Bahçecioğlu. Prevalence of helicobacter pylori infection and its histopathological correlation in adult celiac patients. Ann Clin Anal Med 2025;16(Suppl 3):S211-214
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Psychological resilience, perceived stress, and emotional eating behavior: Their impact on type 2 diabetes risk
Sedat Özdemir 1, Özlem Kardaş Kin 2, Emel Gulbahar 3
1 Department of Internal Medicine, Gaziantep Islamic Science and Technology University, Gaziantep, Turkiye, 2 Department of Operating Room Services, Vocational School of Health Services, Gaziantep Islamic Science and Technology University, Gaziantep, Turkiye, 3 Department of Clinical Psychology, Oğuzeli State Hospital, Gaziantep, Turkiye
DOI: 10.4328/ACAM.22938 Received: 2025-10-09 Accepted: 2025-10-24 Published Online: 2025-10-24 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S215-220
Corresponding Author: Ozlem Kardas Kin, Department of Operating Room Services, Vocational School of Health Services, Gaziantep Islamic Science and Technology University, Gaziantep, Turkiye. E-mail: kardas.ozlem@hotmail.com P: +90 342 909 75 00 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6637-5786
Other Authors ORCID ID: Sedat Ozdemir, https://orcid.org/0000-0003-3858-2408 . Emel Gulbahar, https://orcid.org/0009-0000-2142-7773
This study was approved by the Ethics Committee of Gaziantep Islamic Science and Technology University (Date: 2025-06-29, No: 2025-2ÖNP-0264)
Aim: This study aims to investigate the impact of coping mechanisms—particularly emotional eating behavior—on the risk of developing Type 2 diabetes among individuals with low psychological resilience and high perceived stress levels.
Materials and Methods: A cross-sectional research design was employed, including 328 participants. Data were collected using the “Personal Information Form”, “Emotional and Stress-Related Eating and Evaluation Scale”, and “Psychological Resilience Scale (PRS)”.
Results: An increase in the Challenge subscale score was found to significantly decrease the risk of Type 2 diabetes, whereas higher scores on the Difficulty in Coping subscale were associated with an increased risk. A positive correlation was identified between body mass index (BMI) and emotional/stress-related eating, while a negative correlation was observed between psychological resilience and BMI. Female participants demonstrated significantly higher levels of emotional eating and perceived stress compared to males.
Discussion: Psychological resilience and effective coping strategies serve as protective factors against stress and emotional eating behaviors that influence the risk of Type 2 diabetes and BMI. Considering gender differences, the development of individualized and interdisciplinary interventions within the fields of nursing, medicine, and psychology is recommended.
Keywords: type 2 diabetes, psychological resilience, perceived stress, emotional eating
Introduction
It is thought that as exposure to stressors increases and emotional arousal intensifies, individuals may fail to distinguish between physical hunger and emotional cues, perceiving this arousal as hunger and consequently exhibiting a tendency toward overeating. Research supporting this view indicates that individuals exposed to high levels of stress tend to engage in increased food intake [1,2].
The perception of chronic illness, its impact on daily life, and the complications that develop during the disease process can lead to psychological problems. While blood glucose levels can induce mood changes, psychological problems, and stress, they also serve as risk factors in the development and progression of diabetes. Although individuals with diabetes are frequently monitored for glycemic control and complications, their psychological states are often not adequately assessed [3]. Since blood glucose levels directly affect brain function and emotional states, emotional and psychological changes, in turn, influence glucose regulation [4]. Wojujutari et al. (2024) reported that the relationship between psychological resilience and depression is particularly pronounced among individuals with Type 2 diabetes [5]. According to Fletcher and Sarkar (2013), psychological resilience refers to an individual’s ability to maintain positive adaptation and functioning in the face of adversity or significant stressors [6], while Bartone et al. (2008) conceptualized it as a personality trait that enhances one’s capacity to cope with stress [7]. Navuluri (2000) found that individuals with diabetes who have higher levels of psychological resilience tend to use self-management strategies more effectively to control their condition [8]. Similarly, Bartone et al. (2016) demonstrated that individuals with lower levels of psychological hardiness exhibited higher blood pressure and unfavorable lipid profiles, suggesting that reduced resilience may contribute to increased cardiovascular and metabolic risk [9].
Previous studies have reported that individuals with diabetes exhibit higher rates of eating disorders, disordered eating behaviors, and post-traumatic stress symptoms compared to non-diabetic individuals. Those who experience frequent hypoglycemic episodes have been found to develop long-term personality changes, depression, cognitive impairments, and, in rare cases, psychotic symptoms [10,11]. Baran et al. (2020) identified food addiction in 39.1% of individuals with Type 2 diabetes [12].
When evaluating individuals’ dietary patterns or proposing lifestyle modifications, it has been emphasized that a multidimensional approach—taking into account factors such as food addiction—yields more effective outcomes [13]. In particular, understanding the relationship between eating behaviors and psychological resilience can contribute to more effective management of Type 2 diabetes. Therefore, the aim of this study is to examine the effects of coping mechanisms — particularly emotional eating behavior — on the risk of developing Type 2 diabetes among individuals with low psychological resilience and high perceived stress.
Materials and Methods
Study Design
This research was designed as a descriptive and cross-sectional study. This study used a cross-sectional design; therefore, findings indicate associations only and cannot infer causality. A total of 328 individuals who applied to the Internal Medicine Outpatient Clinic of Gaziantep Oğuzeli State Hospital between September and October 2025 and met the inclusion criteria were included in the study.
Sample
Assuming an unknown prevalence of 50%, with a 5% margin of error and a 95% confidence interval, the minimum sample size for an unknown population was calculated as 384 [14]. When the size of the target population is unknown, the formula n = t²pq/d² is applied: n = 1.96² × (0.5 × 0.5) / 0.05² = 384.16.
In our study, although the planned sample size was 384 participants, a total of 328 participants were reached based on voluntary participation during the data collection process. To assess the impact of this difference on statistical power, a post-hoc power analysis was conducted. The analysis indicated that with a 95% confidence level, a 5% margin of error, and a target power of 80%, the sample size of 328 was sufficient. This result ensures the reliability and validity of the statistical analyses.
Inclusion Criteria
• Individuals aged 18 years and older
• Voluntary participation in the study
Exclusion Criteria
• Unwillingness to participate in the study
Data Collection Tools
To ensure confidentiality, the questionnaire form was created using a Google Forms URL. The survey link was distributed to students and healthcare professionals via WhatsApp. Prior to completing the survey, participants were informed about the study’s purpose, and their consent was obtained. Participants were invited via an online survey, and the proportion of healthcare workers in the sample may represent a potential sampling bias. This limitation has been considered in the interpretation of the findings.
Personal Information Form; developed by the researchers based on a review of the literature, this form includes 11 questions evaluating participants’ sociodemographic characteristics and diabetes-related conditions [1,4].
Emotional and Stress-Related Eating and Evaluation Scale (EADES); this instrument was developed by Ozier et al. (2022) to assess individuals’ emotional eating behaviors and stress-related eating habits [15]. The Turkish adaptation and the validity–reliability study were conducted by Yilmaz (2024) [16]. The scale consists of three subdimensions: (1) emotional and stress-related eating, (2) assessment of coping ability and resources, and (3) assessment of external influences and stress sources. These subscales are scored within the following ranges: 24–120, 20–100, and 5–25, respectively. Items are rated on a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The Cronbach’s alpha coefficients for the three factors were found to be F1 = 0.935, F2 = 0.902, and F3 = 0.708, indicating moderate to high reliability.
Psychological Resilience Scale (PRS); developed by Isik (2016), the PRS is a five-point Likert-type instrument ranging from (0) “strongly disagree” to (4) “strongly agree” [17]. It consists of 21 items reflecting individuals’ beliefs about life and themselves, with items 2 and 15 reverse-scored. Exploratory and confirmatory factor analyses confirmed the scale’s three-factor structure, comprising Commitment (items 1, 2, 3, 5, 6, 18, 21), Control (items 4, 10, 11, 12, 15, 19, 20), and Challenge (items 7, 8, 9, 13, 14, 16, 17). The Cronbach’s alpha reliability coefficient was .76 for the total scale, and .62, .69, and .74 for the Commitment, Control, and Challenge subscales, respectively.
Statistical Analysis
Data were analyzed using the SPSS 25.0 statistical package program. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used. Reliability analysis (Cronbach’s alpha), Pearson correlation analysis, independent samples t-test, and one-way ANOVA were employed for data interpretation. The normality of numerical variables was assessed using skewness and kurtosis values. Pearson correlation analysis was used to examine the relationships between continuous variables. Differences between two independent groups were analyzed using the t-test, while one-way ANOVA was applied for comparisons among three or more groups. Logistic regression analysis was performed to evaluate the influence of relevant parameters. A significance level of p < 0.05 was considered statistically significant.
Ethical Approval
This study was approved by the Ethics Committee of Gaziantep Islamic Science and Technology University (Date: 2025-06-29, No: 2025-2ÖNP-0264).
Results
Among the 328 participants included in the study, 56.7% were female and 43.3% were male, with the majority being single (60.7%). Regarding educational level, most participants were university graduates (45.7%), followed by those with primary (21.6%), secondary (10.4%), and high school (12.8%) education; 5.8% held a postgraduate degree. In terms of lifestyle factors, 20.7% were current smokers and 9.1% were former smokers, while alcohol use was reported by 8.5% (current) and 7.3% (former) of the participants. Approximately half of the sample (49.1%) reported having a chronic disease, and 42.7% had been diagnosed with Type 2 diabetes. The mean age of participants was 40.83 ± 17.87 years (range: 18–94), and the mean body mass index (BMI) was 27.06 ± 5.6, indicating that participants were, on average, overweight to mildly obese. This demographic and clinical composition provides an appropriate sample for evaluating the effects of psychological resilience, stress, and eating behaviors on Type 2 diabetes and metabolic health.
A significant positive correlation was observed between age and BMI (r = 0.52, p < 0.001), indicating that BMI increases with age. Emotional and stress-related eating was moderately and positively correlated with BMI (r = 0.28, p < 0.001), suggesting that emotional eating behaviors are associated with higher BMI. The difficulty in coping subscale was positively correlated with both BMI (r = 0.13, p < 0.01) and emotional/stress-related eating (r = 0.16, p < 0.01), implying that individuals with poorer coping abilities tend to engage more in emotional eating and have higher BMI values.
Negative correlations were found between the psychological resilience subscales (commitment, control, and challenge) and BMI (r ranging from –0.20 to –0.41, p < 0.001), indicating that higher resilience is associated with lower BMI. A strong negative relationship was also observed between total psychological resilience and difficulty in coping (r = –0.61, p < 0.001), showing that resilience is inversely related to perceived coping difficulty. Moreover, a significant positive correlation was identified between emotional/stress-related eating and external stressors (r = 0.31, p < 0.001), suggesting that external stress stimuli may increase emotional eating behavior. Overall, the observed correlations were consistent with prior literature indicating inverse associations between psychological resilience and both BMI and emotional eating.
Gender-based analyses revealed that females scored significantly higher than males on the emotional and stress-related eating (t = 2.89, p = 0.004, d = 0.32) and external stressors (t = 3.75, p < 0.001, d = 0.42) subscales. These findings suggest that women are more vulnerable to stress-induced eating behaviors and external stress stimuli (Table 1). No significant gender differences were found in difficulty in coping, commitment, control, challenge, or total psychological resilience scores (p > 0.05). This indicates that coping abilities and resilience levels are similar across genders, but women may be more sensitive to emotional and stress-related eating. Overall, these findings highlight the potential importance of gender-specific interventions aimed at reducing stress and emotional eating, particularly among women.
Analyses based on the presence of Type 2 diabetes revealed that individuals with diabetes had significantly higher difficulty in coping scores (t = –2.77, p = 0.005, d = –0.31), suggesting greater challenges in managing stress. Although differences in emotional and stress-related eating and external stressors were not statistically significant, emotional eating scores were slightly higher among participants with diabetes (p = 0.09). Scores on the psychological resilience subscales — commitment (t = 3.89, p = 0.001, d = 0.43), control (t = 5.04, p = 0.001, d = 0.56), challenge (t = 6.79, p = 0.001, d = 0.76) — as well as total resilience (t = 5.95, p = 0.001, d = 0.66) were significantly higher in non-diabetic participants. These findings suggest that psychological resilience may play a protective role in reducing Type 2 diabetes risk and underscore the importance of enhancing coping strategies in diabetes management (Table 2).
Logistic regression analysis demonstrated that emotional and stress-related eating and difficulty in coping did not significantly predict Type 2 diabetes (p > 0.05). However, external stressors significantly increased diabetes risk (p = 0.02; Exp (B) = 1.04), while total psychological resilience and the challenge subscale significantly decreased it (p < 0.001; Exp (B) = 0.94 and 0.83, respectively). These findings indicate that higher psychological resilience — particularly the ability to view stress as a challenge — serves as a protective factor against Type 2 diabetes, whereas exposure to external stressors increases the risk (Table 3).
Discussion
In this study, while the control and commitment subscales of psychological resilience did not significantly predict Type 2 diabetes, each one-point increase in the challenge subscale reduced the likelihood of diabetes by approximately 15%. Similarly, Mohammadi et al. (2022) reported that all three dimensions of psychological resilience — control, commitment, and challenge — were positively correlated with illness perception and self-efficacy among individuals with diabetes [18]. Consistent with these findings, a one-unit increase in psychological resilience was shown to decrease the likelihood of developing Type 2 diabetes by 5%. Moreover, Wojujutari et al. (2024) demonstrated that psychological resilience partially mediated the relationship between diabetes-related stress and depression (b = –0.10, p < 0.05) [5]. These findings indicate that psychological resilience plays a crucial role in preventing the transformation of stress into depression. While the stress–depression link tends to be more pronounced among individuals with Type 1 diabetes, the protective effect of resilience appears stronger among those with Type 2 diabetes. The observed associations may be explained by underlying biological mechanisms. Chronic exposure to stress and external stressors can elevate cortisol levels, which in turn may contribute to insulin resistance and impaired glucose regulation. This stress hormone response can promote emotional eating behaviors, weight gain, and metabolic dysregulation, thereby increasing the risk of Type 2 diabetes. Conversely, higher psychological resilience may buffer the physiological impact of stress, helping to maintain more stable cortisol levels and better metabolic control.
Logistic regression analyses revealed that emotional and stress-related eating and perceived stress subscales did not significantly predict Type 2 diabetes; however, increases in difficulty in coping scores significantly elevated the risk of developing diabetes. This finding aligns with the studies of Hackett and Steptoe (2017) and Sinha and Jastreboff (2013), both of which emphasized that psychological stress and inadequate coping contribute to the etiology of Type 2 diabetes by promoting metabolic dysregulation and energy imbalance [19,20]. The logistic regression results indicate that total psychological resilience (Exp (B) = 0.94) and the challenge subscale (Exp (B) = 0.83) significantly reduce the risk of Type 2 diabetes, whereas external stressors increase the risk (Exp (B) = 1.04). These findings quantitatively demonstrate the protective role of psychological resilience and the risk-enhancing effect of external stress. Gender analyses further support that women are more sensitive to stress-induced eating behaviors, as indicated by Cohen’s d values (d = 0.32–0.42).
In the present study, body mass index (BMI) was positively correlated with emotional and stress-related eating but negatively correlated with psychological resilience. These results are consistent with prior literature suggesting that difficulty in coping with stress and emotional eating behaviors are significant determinants of BMI. Guerrini-Usubini et al. (2023) reported that difficulties in emotion regulation increase psychological distress and emotional eating, consequently elevating BMI [21]. Likewise, Braden et al. (2025) found that emotional eating is particularly prevalent among obese adults and shows a positive association with BMI [22]. Accordingly, psychological resilience and effective coping strategies may protect metabolic health by preventing excessive weight gain, and interventions aimed at strengthening emotional regulation could yield beneficial outcomes for both psychological and physical well-being.
Gender-based analyses revealed that, while no differences were observed in psychological resilience or coping difficulty, women reported significantly higher levels of emotional and stress-related eating and perceived stress compared to men. This finding is in line with Du et al. (2022), who found that emotional eating mediates the relationship between perceived stress and BMI among women [23]. From a sociocultural perspective, women’s stress coping styles and emotional eating behaviors may be influenced by societal expectations and cultural norms. Studies indicate that women are more sensitive to social pressures regarding body image and appearance, which can exacerbate emotional eating and stress responses [24]. Furthermore, difficulties in emotional regulation have been shown to contribute to stress-induced eating behaviors among women [24,25]. Cultural context also plays a significant role, as evidenced by research demonstrating that women’s experiences of emotional eating are shaped by the prevailing social norms and values in their communities [25]. Therefore, gender-sensitive psychological interventions and coping strategies should not only address individual behavioral and emotional factors but also consider the broader sociocultural influences that may affect women’s stress and eating patterns.
Limitations
This study has several limitations. First, its cross-sectional design prevents the establishment of causal relationships between psychological resilience, emotional eating, perceived stress, and the risk of Type 2 diabetes. Second, self-reported data may be subject to recall and social desirability bias. Third, the sample was limited to individuals applying to a single hospital, which may restrict the generalizability of the findings to broader populations. In addition, the use of an online questionnaire for part of the data collection may have excluded individuals with limited internet access or technological literacy. Future longitudinal and multi-center studies using objective clinical and biochemical measures are recommended to confirm and expand upon these findings.
Conclusion
This study demonstrates that psychological resilience plays a significant role in reducing the risk of Type 2 diabetes and mediating the relationship between stress and depression. While difficulty in coping, emotional eating, and stress-related factors exerted a limited effect on diabetes risk, the observed associations between BMI, emotional eating, and gender differences highlight the relevance of metabolic and psychological interconnections. The higher levels of emotional eating and perceived stress among women underscore the necessity of gender-specific interventions. Strengthening psychological resilience and coping mechanisms may serve as protective factors for both mental and metabolic health.
Professional Recommendations
Nurses: Assess stress, emotional eating, and coping difficulties; provide brief counseling and educational interventions to enhance resilience.
Physicians: Include stress management and behavioral interventions in treatment plans, alongside routine metabolic monitoring.
Psychologists: Implement cognitive-behavioral and mindfulness-based programs to improve emotion regulation and coping, tailored to individual and gender-specific needs.
Overall, fostering resilience-based, gender-sensitive, and interdisciplinary strategies could significantly contribute to the prevention and management of Type 2 diabetes.
Acknowledgment
I would like to thank all those involved in the realisation of this work, each person by name; I am truly grateful for their input and encouragement.
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, and 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.
References
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2. Wallis DJ, Hetherington MM. Emotions and eating: self-reported and experimentally induced changes in food intake under stress. Appetite. 2009;52(2):355-62.
3. Bahar A, Tanrıverdi D. Diabetes from psychiatric and psychosocial aspects: a review. Neuropsychiatr Invest. 2017;55(2):13-8.
4. Güclü YA, Yıldız ED, Unsal F, Ongel K. Evaluation of the quick self-rated depressive symptoms inventory form and beck depression inventory for diabetic patients. Anatol J Gen Med Res. 2013;23(3):113-9.
5. Wojujutari AK, Idemudia ES, Ugwu LE. Psychological resilience mediates the relationship between diabetes distress and depression among persons with diabetes in a multi-group analysis. Sci Rep. 2024;14(1):6510.
6. Fletcher D, Sarkar M. Psychological resilience: A review and critique of definitions, concepts, and theory. Eur Psychol. 2013;18(1):12–23.
7. Bartone PT, Roland RR, Picano JJ, Williams TJ. Psychological hardiness predicts success in US Army Special Forces candidates. Int J Sel Assess. 2008;16(1):78-81.
8. Navuluri R. Do hardiness and attitude promote self-care adherence to physical activity among adults with diabetes? Internet J Intern Med. 2000;3(1):1-10.
9. Bartone PT, Valdes JJ, Sandvik A. Psychological hardiness predicts cardiovascular health. Psychol Health Med. 2016;21(6):743-9.
10. Kücük L. Psychological aspects of diabetes. Eur Arch Med Res. 2015;31(Suppl.):52-6.
11. Nefs G, Speight J, Pouwer F, Pop V, Bot M, Denollet J. Type D personality, suboptimal health behaviors and emotional distress in adults with diabetes: results from Diabetes MILES–The Netherlands. Diabetes Res Clin Pract. 2015;108(1):94-105.
12. Baran M, Türker PF. Evaluation of nutritional and food addiction status of individuals with type 2 diabetes presenting to Ankara Baskent Hospital. ASNH. 2021;5(3):82-9.
13. Cim EF, Atli A. Food addiction. J Dependence. 2017;18(3):90-7.
14. Ozdamar K. Modern scientific research methods. Eskişehir: Kaan Publishing; 2003.
15. Ozier AD, Kendrick OW, Knol LL, Leeper JD, Perko M, Burnham J. The Eating and Appraisal Due to Emotions and Stress (EADES) Questionnaire: development and validation. J Am Diet Assoc. 2007;107(4):619-28.
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17. Isik S. Development of the Psychological Resilience Scale: validity and reliability study. J Happiness Well-Being. 2016;4(2):165-82.
18. Mohammadi F, Tehranineshat B, Farjam M, Rahnavard S, Bijani M. The correlation between resilience, self-efficacy, and illness perception in patients with type 2 diabetes: a cross-sectional study. Clin Diabetol. 2022;11(3):175-82.
19. Hackett RA, Steptoe A. Type 2 diabetes mellitus and psychological stress—a modifiable risk factor. Nat Rev Endocrinol. 2017;13(9):547-60.
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Sedat Özdemir, Özlem Kardaş Kin, Emel Gulbahar. Psychological resilience, perceived stress, and emotional eating behavior: Their impact on type 2 diabetes risk. Ann Clin Anal Med 2025;16(Suppl 3):S215-220
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A case of measles during pregnancy: Case report and management
Mirkan Bulğak
Department of Infectious Diseases, Faculty of Medicine, Izmir Universty of Economics, Medical Point Hospital, Izmir, Turkey
DOI: 10.4328/ACAM.22455 Received: 2024-10-14 Accepted: 2024-11-18 Published Online: 2024-12-03 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3):S221-223
Corresponding Author: Mirkan Bulğak, Department of Infectious Diseases, Faculty of Medicine, Izmir Universty of Economics, Medical Point Hospital, Izmir, Turkey. E-mail: mirkanbulgak@gmail.com P: +90 532 792 31 79 Corresponding Author ORCID ID: https://orcid.org/0000-0003-3020-9414
Measles is a viral infection known for its high contagiousness and serious complications. It caused approximately 136,00 deaths worldwide in 2022. It may lead to more severe complications in pregnant women due to the weakened immune system. In this article, the symptoms, complications, and treatment process of a 26-year-old woman who had measles while five weeks pregnant were examined. The patient presented with symptoms of upper respiratory tract infection, but treatment was started after a maculopapular rash and positive measles PCR test. During the treatment process, nasal oxygen, antihistamines, and other supportive treatments were administered to control complications. Since measles infection during pregnancy carries serious risks, early diagnosis and close follow-up are important. Additionally, it is emphasized that vaccination rates should be increased.
Keywords: Pregnancy, Measles, Complications, Measles Treatment
Introduction
The measles virus is a highly contagious pathogen that spreads easily through the air and can cause severe complications in infected individuals. According to the reports of the World Health Organization (WHO) reports, approximately 136,000 people worldwide died due to measles in 2022 [1]. Measles can cause serious complications such as pneumonia, otitis, conjunctivitis, hepatitis, thrombocytopenia, and fetal death in pregnant women [2]. In this case, the clinical course and treatment management of a patient who had measles during the fifth week gestation period are presented. Informed consent was obtained from the patient.
Case Report
A 26-year-old, five-week pregnant woman with no known comorbidities presented to the emergency room with complaints of sore throat, headache, cough, and widespread body pain. Initially diagnosed with upper respiratory tract infection, symptomatic treatment was prescribed, and she was discharged from the emergency department. However, on the fourth day of her symptoms, she developed maculopapular rashes starting from her neck and progressing to the trunk. The patient returned to the hospital and was admitted to the infectious diseases unit with a preliminary diagnosis of measles. There was no history of measles exposure in her family or surroundings. The patient had no known allergy history and no measles vaccination. In her physical examination during her first hospitalization, his general condition was fair to good; she was conscious, cooperative, and oriented. The oropharynx was hyperemic, but there was no Koplik’s spot, and rales were heard in the bases when auscultating the lungs. Maculopapular rashes were widespread, mostly on the trunk. The patient’s arterial blood pressure was 110/80 mm/Hg, oxygen saturation: 90%, respiratory rate: 24/min, laboratory tests show leukocyte count in blood: 9240/μL, lymphocyte count: 3810/μL, platelet: 110,000/ml, CRP: 25 mg/L, AST: 120 ALT: 147, total bilirubin: 0.3 mg/dL, anti-HIV: negative, VDRL: negative.
The patient was started on nasal oxygen support, antihistamines, paracetamol, and intravenous 0.9% isotonic saline solution. A nasopharyngeal swab was sent for measles PCR testing. For fetal well-being, she was consulted by the obstetrics and gynecology department every other day. The rashes did not respond to antihistamine treatment. On the third day of her hospitalization, the patient’s platelet count dropped to 35,000/μL, and platelet monitoring was performed twice daily until the values improved. The patient developed otitis, and treatment with 1 g of ceftriaxone IV twice a day was initiated. By the fourth day of her hospitalization, she no longer required oxygen support. On the sixth day, her rashes faded, and AST and ALT levels returned to normal. The patient, who did not require platelet replacement, had a platelet count of 168,000/μL on the seventh day. The measles PCR result was positive. The obstetrics and gynecology department indicated that there was no risk of miscarriage and that the patient had no active complaints, so she was discharged with a recommendation for routine follow-up at the obstetrics and gynecology outpatient clinic.
Discussion
Measles can lead to more serious complications, especially in pregnant women, due to their suppressed immune system. The risk of measles infection in pregnant women increases due to the weakened immune response against viral infections [3]. This may lead to a more severe course of the infection and the emergence of more serious complications. Complications of thrombocytopenia, otitis, and hepatitis were observed in our case. Thrombocytopenia is one of the rare but known complications of measles and is important in terms of bleeding risk [4]. Complications such as otitis and hepatitis may also occur more frequently, especially during pregnancy, due to the weakened immune system [2].
The risks caused by the measles virus during pregnancy are quite serious for both the mother and the fetus. Pregnant women with measles infection may experience consequences such as premature birth, miscarriage, intrauterine growth retardation, and fetal death. Therefore, it is important to closely monitor the health status of the fetuses of infected pregnant women. These complications may result from hormonal and immune changes during pregnancy. In women who have measles during pregnancy, early diagnosis, and ongoing follow-up are essential to maintain the health of the fetus and prevent complications. Supportive treatment plays an important role in reducing complications and relieving symptoms [5].
In recent years, the incidence of measles has increased in our country, and according to WHO data, Turkey has one of the highest numbers of measles cases in the European region [6]. This increase is due to low vaccination rates and insufficient immunization efforts in the community. Measles vaccination history should be questioned during routine pre-pregnancy screening, and unvaccinated women should be vaccinated. Since the measles vaccine is a live vaccine, it is not recommended to be administered during pregnancy; however, it is extremely important for women planning pregnancy to be informed and vaccinated before pregnancy [7].
Conclusion
Our experience with this case emphasizes the seriousness of measles infection during pregnancy and the need for careful management of complications. Patients who have measles during pregnancy should be closely monitored for fetal death, premature birth, and other complications. The importance of measles vaccination is an issue that should be kept on the agenda by physicians for both individual and public health.
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, and 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.
Conflict of interest
The authors declare that there is no conflict of interest.
References
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2. Congera P, Maraolo AE, Parente S, Schiano Moriello N, Bianco V, Tosone G. Measles in pregnant women: A systematic review of clinical outcomes and a meta-analysis of antibodies seroprevalence. J Infect. 2020;80(2):152-60.
3. Racicot K, Kwon JY, Aldo P, Silasi M, Mor G. Understanding the complexity of the immune system during pregnancy. Am J Reprod Immunol. 2014;72(2):107-16.
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5. Ogbuanu IU, Zeko S, Chu SY, et al. Maternal, fetal, and neonatal outcomes associated with measles during pregnancy: Namibia, 2009-2010. Clin Infect Dis. 2014;58(8):1086-92.
6. Karabey M, Karabulut N, Alaçam S, Gündüz A, Caymaz C, Altuntaş Aydin Ö. Increase in measles cases in a city hospital, Istanbul, Turkey. Cent Eur J Public Health. 2024;32(2):125-31.
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Mirkan Bulğak. A case of measles during pregnancy: Case report and management. Ann Clin Anal Med 2025;16(Suppl 3):S221-223
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Comment on: Our experience with ERCP (endoscopic retrograde cholangio pancreatography) as the first line treatment for simple bile duct leakage
Guner Kılıç 1, Fatma Yılmaz 2
1 Department of Gastroenterology, 2 Department of Hematology, Ankara Etlik City Hospital, Ankara, Turkey
DOI: 10.4328/ACAM.22539 Received: 2024-12-27 Accepted: 2025-02-04 Published Online: 2025-02-14 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3): DOI: 10.4328/ACAM.22539
Corresponding Author: Guner Kiliç, Department of Gastroenterology, Ankara Etlik City Hospital, Ankara, Turkey. E-mail: gunerrkilic@gmail.com P: +90 532 316 84 21 Corresponding Author ORCID ID: https://orcid.org/0000-0001-6799-3391
Other Authors ORCID ID: Fatma Yilmaz, https://orcid.org/0000-0001-6112-3950
To the editor:
I read with interest the article titled “Our experiences with ERCP (endoscopic retrograde cholangiopancreatography) as first-line treatment for simple bile duct leakage” by Aydogdu at al, and I would like to share my comments on the study results [1]. ERCP (Endoscopic Retrograde Cholangiography) is an advanced endoscopy method used in the treatment of benign and malignant diseases of the biliary tract and pancreatic duct [2]. Biliary tract injury is a rare but serious complication after surgery and its incidence has been reported to increase especially after the widespread use of laparoscopic cholecystectomy [3]. In patients with biliary injury, the volume, size, and location of the leak are determined by the cholangiogram taken during the ERCP procedure. The stent size and type are determined according to the leak location [4]. The most important cause of procedure failure in biliary leakage is the stent that does not reach the leak site. In this study, 35 of 39 patients with the same type of injury improved after stenting, but four patients did not. Since the type, length, diameter, and number of stents implanted were not specified in the article, it is likely that all of these patients were implanted with standard stents, and four patients failed for this reason. In these four patients, a second procedure performed by experienced endoscopists after the failed ERCP procedure would have been a more appropriate method before surgery. This could have included placing a longer stent proximal to the bile leak, additional stents to prevent migration or the application of a metallic stent.
Ethical Approval
Not required.
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, and 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
No animal or human studies were carried out by the authors for this article.
Funding: None.
Conflict of interest
The authors declare that there is no conflict of interest.
References
1. Aydoğdu YF, Akay T, Çalta AF, Duran A, Oğuz S. Our experience with ERCP (endoscopic retrograde cholangio pancreatography) as the first line treatment for simple bile duct leakage. Ann Clin Anal Med 2024;15(2):122-5.
2. Chen JH, Wang HP. Endoscopic retrograde cholangiopancreatography training and education. Dig Endosc. 2024;36(1):74-85.
3. Connor S, Garden O. Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg. 2006;93(2):158-68.
4. Carr-Locke AD. Biliary stenting alone versus biliary stenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy bile leaks. Eur J Gastroenterol Hepatol. 2006;18(10):1053-5.
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Guner Kılıç, Fatma Yılmaz. Comment on: Our experience with ERCP (endoscopic retrograde cholangio pancreatography) as the first line treatment for simple bile duct leakage. Ann Clin Anal Med 2025;16(Suppl 3): DOI: 10.4328/ACAM.22539
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Comment on: Effect of side branch predilatation before provisional stenting in coronary bifurcation lesions
Musa İlker Durak
Department of Cardiology, Etlik City Hospital, Ankara, Turkiye
DOI: 10.4328/ACAM.22912 Received: 2025-09-23 Accepted: 2025-10-23 Published Online: 2025-10-23 Printed: 2025-10-25 Ann Clin Anal Med 2025;16(Suppl 3): DOI:10.4328/ACAM.22912
Corresponding Author: Musa İlker Durak, Department of Cardiology, Etlik City Hospital, Ankara, Turkiye. E-mail: ilkerdurak@gmail.com P: +90 533 710 67 67 Corresponding Author ORCID ID: https://orcid.org/0000-0003-2232-4316
To the editor:
We read with considerable interest the recent article by Kanal et al. entitled “Effect of side branch predilatation before provisional stenting in coronary bifurcation lesions” published in your journal [1]. The authors address a clinically relevant and debated aspect of interventional cardiology, and their work contributes valuable real-world evidence to the literature on bifurcation percutaneous coronary intervention (PCI).
The study’s primary conclusion, that routine side branch (SB) predilatation is associated with a higher incidence of procedural complications such as dissection and an increased need for kissing balloon inflation, is a significant finding that reinforces current guideline recommendations. However, we wish to raise several methodological considerations that are crucial for the interpretation of these results.
The most salient point is the pronounced selection bias inherent in the study’s non-randomized design. The decision to perform predilatation was operator-dependent, and the predilatation group exhibited significantly more severe SB ostial stenosis (80% vs. 50%, p < 0.001). This indicates that the technique was selectively applied to more complex and high-risk lesions. Consequently, the higher complication rate observed in the predilatation group may be more reflective of this underlying lesion complexity than a direct effect of the predilatation strategy itself. A multivariate analysis adjusting for key angiographic parameters, such as stenosis severity and lesion morphology, would help to isolate the independent effect of predilatation.
Furthermore, the intriguing subgroup analysis suggesting a more favorable safety profile with non-compliant (NC) balloons warrants cautious interpretation. The sample size for the NC-only predilatation group (n = 12) is limited, and the comparison with the semi-compliant balloon group may be underpowered. While this observation is hypothesis-generating, it highlights the need for prospective studies specifically designed to evaluate the impact of balloon technology on SB outcomes.
Finally, the clinical implications of the study would be strengthened by data on longer-term endpoints. Information on in-hospital or follow-up major adverse cardiac events (MACE), including target vessel revascularization (TVR), would be invaluable. As suggested by prior studies like that of Vassilev et al., procedural outcomes do not always correlate with long-term clinical success [2].
In conclusion, we congratulate the authors on their valuable contribution. Their findings aptly caution against the routine use of SB predilatation. We agree that future prospective, randomized trials are essential to definitively determine whether a selective strategy, potentially utilizing NC balloons in specific high-risk anatomical subsets, can improve patient outcomes.
Ethical Approval
Not required.
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, and 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
No animal or human studies were carried out by the authors for this article.
Funding: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Conflict of interest
None.
References
1. Kanal Y, Ayhan G, Koç ÜN. Effect of side branch predilatation before provisional stenting in coronary bifurcation lesions. Ann Clin Anal Med. 2025;16(9):608-12.
2. Vassilev D, Mileva N, Panayotov P, et al. Side branch predilatation during percutaneous coronary bifurcation intervention: long-term mortality analysis. Kardiol Pol. 2024;82(4):398-406.
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Musa İlker Durak. Comment on: Effect of side branch predilatation before provisional stenting in coronary bifurcation lesions. admissions. Ann Clin Anal Med 2025;16(Suppl 3): 10.4328/ACAM.22912
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