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Objective: This study aims to evaluate the necessity of ear packing in otological operations where the annulus fibrosus is not elevated, focusing on graft success rates and postoperative hearing outcomes., Methods: A randomized controlled prospective clinical trial was conducted at a tertiary care hospital involving 200 patients aged 18 years and above undergoing myringoplasty for inactive chronic suppurative otitis media. Patients were randomly assigned to receive either ear packing with absorbable gelatin sponge (Gelfoam®) or no packing. The primary outcome is graft success assessed via microscopic examination at 3 and 6 months post-surgery. Secondary outcomes include hearing gains measured by pure-tone audiometry at 500-, 1000-, 2000-, and 4000-Hz frequencies., Results: At 3 months, the graft take rate was 92% in the ear packing group and 90% in the no packing group, with no statistically significant difference (p = 0.63). At 6 months, the graft take rate was 90% in the packing group and 88% in the no packing group (p = 0.67). Hearing improvements, as measured by air conduction thresholds, were also similar between the two groups (p = 0.73)., Conclusion: This study demonstrates that myringoplasty without ear packing yields comparable graft take rates and hearing improvements to traditional myringoplasty with ear packing. These findings suggest that omitting ear packing in appropriate cases may simplify the procedure without compromising patient outcomes., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Abstract: Our aim is to reveal the interaction of cultural and religious influences with professional equipment by determining the level of knowledge, sexual attitudes, and homophobia of medical students about LGBTI+ individuals. The study included 324 students from our faculty of medicine. The Hudson and Ricketts Homophobia scale, the Attitudes Towards Lesbians and Gay Men scale, and the Hendrick Sexual Attitudes scale were used with the sociodemograpic data form. Data were collected and analyzed using descriptive and inferential statistical tests. The mean score of the students from the Hudson and Ricketts Homophobia scale was 58.50. The findings of our study support that medical students consider that the education they receive in this regard is inadequate. One of the goals of undergraduate medical education is the provision of health services to all segments of society; therefore, it is recommended to make improvements in the curriculum in this regard., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head computed tomography scan, a considerable portion of the cases have intracranial imaging abnormalities on computed tomography scan. Whereas other intracranial pathological findings have been extensively studied, little is known about the clinical significance of pneumocephalus in pediatric mTBI., Methods: We retrospectively identified pediatric mTBI patients with pneumocephalus using the institutional database of a large regional trauma referral center. Outcome measures were defined as clinically important TBI (ciTBI), hospitalization, intensive care unit (ICU) admission, and neurosurgical intervention. Comparisons were made between pneumocephalus and control (isolated linear fracture) groups as well as between isolated (only linear fracture and pneumocephalus) and nonisolated pneumocephalus (pneumocephalus and TBI) groups., Results: Among 3524 pediatric mTBI cases, 43 cases had pneumocephalus (1.2%). Twenty-one cases (48.8%) had isolated pneumocephalus. The pneumocephalus group had higher rates of ciTBI, hospital admission, ICU admission, and neurosurgery when compared with the isolated linear fracture (control) group. The isolated pneumocephalus group had fewer ciTBI (21.1% vs 70%, P = 0.002), fewer hospitalization (23.8% vs 81.8%, P < 0.001), but similar ICU admission rates (4.8% vs 22.7%, P = 0.089) and length of hospital stay (4.0 ± 2.7 vs 3.6 ± 2.4 days, P = 0.798) in comparison to the nonisolated pneumocephalus group. None of the patients in the isolated group had neurosurgery whereas 2 patients in the nonisolated pneumocephalus group underwent surgery. Multivariable analysis revealed pneumocephalus as an independent predictor of ciTBI and hospital admission, but not ICU admission or neurosurgical intervention., Conclusion: Pneumocephalus is associated with increased rates of hospitalization and ciTBI, but not ICU admission, unfavorable outcome, or neurosurgical intervention in pediatric mTBI. Although usually spontaneously resolving pathology, it may occasionally be linked with complications such as cerebrospinal fluid leakage, meningitis, and tension pneumocephalus. Therefore, careful evaluation, close observation, and early detection of complications may prevent adverse outcomes., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To analyze the effects of the bimaxillary orthognathic surgery on the voice characteristics of skeletal Class III cases, and to evaluate correlations between acoustic and skeletal changes., Method: Skeletal Class III adult patients (7 male, 18 female) were asked to pronounce the sounds "[a], [ɛ], [ɯ], [i], [ɔ], [œ], [u], [y]" for 3 seconds. Voice records and lateral cephalometric x-rays were taken before the surgery (T0) and 6 months after (T1). Voice records were taken for the control group with 6 months of interval (n=20). The formant frequencies (F0, F1, F2, and F3), Shimmer, Jitter and Noise to Harmonic Ratio (NHR) parameters were considered with Praat version 6.0.43., Results: In the surgery group, significant differences were observed in the F1 of [e], F2 and Shimmer of [ɯ] and F1 and F2 of [œ] and F1 of [y] sound, the post-surgery values were lower. F3 of [u] sound was higher. In comparison with the control group, ΔF3 of the [ɔ], ΔF3 of the [u] and ΔF1 of the [y] sound, ΔShimmer of [ɛ], [ɯ], [i], [ɔ], [u] and [y], and the ΔNHR of [ɔ] sound significantly changed. The Pearson correlation analysis proved some correlations; ΔF2 between ΔSNA for [ɯ] and [œ] sounds, ΔF1 between ΔHBV for [y] sound., Conclusion: Bimaxillary orthognathic surgery changed some voice parameters in skeletal Class III patients. Some correlations were found between skeletal and acoustic parameters. We advise clinicians to consider these findings and inform their patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objectives: To determine the prevalence and time course of thiamine deficiency (TD) in PICU patients., Design: Multicenter, prospective, cohort study between May 2019 and November 2019., Setting: Three university-based tertiary care, mixed medical-surgical PICUs in Ankara, Turkey., Patients: PICU patients 1 month to 18 years old., Interventions: None., Measurements and Main Results: We studied 476 patients and grouped them by TD status on days 1 and 3 of the PICU admission. There might be a risk of unintended bias since we excluded 386 patients because of the absence of consent, inadequate blood samples, loss of identifier information, and recent vitamin supplementation. On day 1, TD was present in 53 of 476 patients (11.1%) and median (minimum-maximum) thiamine levels were 65.5 ng/mL (5-431 ng/mL). On day 3, TD was present in 27 of 199 patients (13.6%) with repeated measurement. The median (minimum-maximum) thiamine levels were 63 ng/mL (13-357 ng/mL). The time course of TD from day 1 to day 3 in these 199 patients was as follows. In 21 of 199 patients (10.6%) with TD on day 1, 11 of 21 (52%) continued to have TD on day 3 and the other 10 of 21 patients (48%) improved to no longer having TD. In 178 of 199 patients (89.4%) without TD on day 1, 16 of 178 (9%) went on to develop TD by day 3, and the other 162 of 178 (91%) continued to have normal thiamine status., Conclusions: In the PICU population in three centers in Turkey, the prevalence of TD in the sample of patients was 11.1%. In those TD patients who had serial studies, we also identified that by day 3 some continued to be TD, and some patients improved to normal thiamine status. Of concern, however, is the population who develop TD over the course of PICU stay., Competing Interests: Dr. Akkuzu’s institution received funding from Gazi University Scientific Research Projects Coordination Unit; he received support for article research from the National Institutes of Health. Dr. Ozcan’s institution received funding from Gazi University; he received support for article research from Gazi University; he disclosed that the corresponding author supplied money to use in this project from the university administration. Drs. Ozcan and Sincar disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background/objective: Juvenile spondyloarthropathies (JSpAs) are a group of inflammatory diseases characterized by asymmetric peripheral arthritis (especially in lower extremities), axial skeleton involvement, and enthesitis. Although cardiovascular findings of inflammatory diseases such as juvenile systemic lupus erythematosus (SLE) and juvenile scleroderma (SD) are well documented, there are only a few studies assessing the cardiovascular consequences of JSpA in the literature., Methods: Forty patients with JSpA and 20 healthy controls were included into this cross-sectional study. Cardiac functions of the participants were evaluated by conventional echocardiography and pulse-wave (PW) tissue Doppler., Results: The patients with JSpA had higher mitral lateral S (p = 0.005) and E' wave (p < 0.001), tricuspid A' wave (p = 0.03), ejection fraction (p = 0.03) and shortening fraction (p = 0.01) than the control patients. In contrast, the patients with JSpA had lower left ventricle MPI (p = 0.01) and the ratio of tricuspid E'/A' waves (p = 0.05). Patients with enthesitis detected on magnetic resonance imaging had lower ejection fraction (p = 0.05), the ratio of E/A waves (p = 0.03) and had higher Mitral lateral A' wave (p = 0.01) than those without. There was a significant inverse correlation between the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and PW transmitral A velocity (r = -0.256, p = 0.03), the BASDAI score and tricuspid annular plane systolic excursion (r = -0.301, p = 0.04), the BASDAI score and the ratio of E/E' waves (r = -0.276, p = 0.02), and the Juvenile Spondyloarthritis Disease Activity Index and PW transmitral A velocity (r = -0.246, p = 0.04)., Conclusions: In this study, we report the possible early signs of RV diastolic dysfunction and possible association between magnetic resonance imaging-confirmed enthesitis and lower LV systolic functions. Early identification of cardiac dysfunctions can help with prevention of long-term cardiovascular complications., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no conflict of interest.

Abstract: This study aimed to determine pain characteristics in patients with persistent headache after COVID-19 and to investigate the role of increased intracranial pressure (ICP) in the pathogenesis of this headache. This is a case-control study comparing the parameters and measurements indicating increased ICP based on magnetic resonance imaging between COVID-19-diagnosed patients with persistent headache and a control group. Optic nerve sheath diameter (ONSD) and eyeball transverse diameter (ETD) were performed on the left eye of each participant. Seventeen of the patients (53.12%) met the diagnostic criteria for new daily persistent headache. Seven patients (21.87%) had migraine, and eight (25%) had tension headache characteristics. No significant difference was observed between the patient and control groups in terms of the ONSD and ETD values. It is possible that the etiopathogenesis is multifactorial. We consider that future studies that will evaluate ICP measurements in large patient groups can present a different perspective for this subject., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Metoclopramide is a commonly used medication in pediatric practice, and dystonia is a common adverse effect of it. The present study aims to evaluate the clinical characteristics of metoclopramide-induced acute dystonic reactions (MIADRs) in pediatric patients admitted to the pediatric emergency unit., Methods: Twenty-eight patients were admitted with MIADRs between June 2004 and April 2016; they were enrolled into the study retrospectively., Results: The study group was composed of 13 females and 15 males with the mean ± SD age of the females higher than that of the males, 12.3 ± 4.5 and 7.8 ± 4.3 years, respectively. Only 9 (32.1%) of the patients were diagnosed as MIADRs at the time of admission. Seventeen patients (60.7%) received over the recommended daily dose of metoclopramide. Dystonia was focal in most of the patients, with the most affected parts consisting of the neck, eyes, and orolingual regions. In 9 of the patients, the dystonia was episodic in nature. Pharmacological treatment was used for 18 patients. No patients died, and none suffered long-term injury related to MIADRs., Conclusions: Metoclopramide administration may be associated with the occurrence of acute dystonic reaction. Metoclopramide-induced acute dystonic reactions may be misdiagnosed, so detailed medical history gathering and a high index of suspicion are warranted. Our data suggest that MIADRs may be dose related and that there may be age- and sex-related differences in the epidemiology of MIADRs., Competing Interests: Disclosure: The authors declared no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Lumbar puncture (LP) is fundamental for diagnosis and treatment; however, some parents do not provide consent for their children to undergo the procedure, which can make diagnosis and determination of the optimal treatment difficult. The present study aimed to describe the level of knowledge and attitudes toward LP of parents whose children were scheduled to undergo the procedure., Methods: A prospective cross-sectional descriptive study of a convenience sample of parents of 84 children aged 2 months to 17 years scheduled for LP at a single academic children's hospital between 2015 and 2017. Parents were administered a written survey and interviewed by a physician other than the person who did the LP. Data on parental level of knowledge and attitudes regarding LP, in addition to reasons for refusal, were collected.The parents of 84 patients scheduled for LP due to various indications were administered a face-to-face survey interview. The survey was used to collect parental demographic data, as well as opinions and knowledge about LP and postinterventional complications., Results: The mean age of the 84 patients (57% male and 43% female) was 6.4 ± 5.17 years. Lumbar puncture was planned for the presumptive diagnosis of neurological disease in 45.25% of the patients, central nervous system infection in 45.25%, and acute encephalopathy in 9.5%. Among the parents, 65% (n = 55) had no knowledge or attitude about LP prior to the survey interview. The most common parental concern related to LP was paralysis (25%), followed by infertility (2%), mental retardation (1%), and disease progression (1%). Only 4.7% of the parents did not provide consent for their child to undergo LP., Conclusions: We found that most parents had little knowledge about LP, and the most common parental concern was paralysis. Despite this, in our study, only 5% of parents did not consent to LP., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective analysis of prospectively collected data., Objective: To report the follow-up curve behaviors in different Sanders staging groups., Summary of Background Data: Vertebral body tethering (VBT) is a growth modulation technique that allows gradual spontaneous follow-up curve correction as the patient grows. There is a lack of scientific evidence regarding appropriate patient selection and timing of implantation., Methods: Patients were grouped into five as: Sanders 1, 2, 3, 4-5, and 6-7. Data were collected preoperatively, at the day before discharge, and at each follow-up. Outcome measures were pulmonary and mechanical complications, readmission, and reoperation rates. Demographic, perioperative, clinical, radiographic, and complication data were compared using Fisher-Freeman-Halton exact tests for categorical variables and Kruskal-Wallis tests for the continuous variables., Results: Thirty-one (29 F, 2 M) consecutive patients with a minimum of 12 months of follow-up were included. The mean age at surgery was 12.1 (10-14). The mean follow-up was 27.1 (12-62) months. The mean preoperative main thoracic curve magnitude was 47° ± 7.6°. For all curves, preoperative and first erect curve magnitudes, bending flexibility, and operative correction percentages were similar between groups (for all comparisons, P > 0.05). The median height gained during follow-up was different between groups (P < 0.001), which was reflected into median curve correction during follow-up. Total curve correction percentage was different between groups (P = 0.009). Four (12.9%) patients had pulmonary and six (19.4%) had mechanical complications. One (3.2%) patient required readmission and two (6.5%) required reoperation. Occurrence of pulmonary complications was similar in Sanders groups (P = 0.804), while mechanical complications and overcorrection was significantly higher in Sanders 2 patients (P = 0.002 and P = 0.018)., Conclusion: Follow-up curve behavior after VBT is different in patients having different Sanders stages. Sanders 2 patients experienced more overcorrection, thus timing and/or correction should be adjusted, since Sanders 3, 4, and 5 patients displayed a lesser risk of mechanical complications., Level of Evidence: 3.

This study aimed to assess whether dabrafenib/trametinib and vemurafenib/cobimetinib treatments are associated with a change in skeletal muscle area (SMA) and total fat-free mass (FFM) assessed by computed tomography (CT), and to compare the efficacy and safety profile of these treatments in patients with metastatic melanoma. Thirty-one patients treated with B-Raf proto-oncogene, serine/threonine kinase/MAPK extracellular receptor kinase inhibitors were included between 2016 and 2019. Eighteen patients received dabrafenib/trametinib and remaining patients received vemurafenib/cobimetinib. CT scans were performed at baseline and at 4-6 months of follow-up to measure cross-sectional areas of SMA. FFM and skeletal muscle index (SMI) values were calculated. Of the patients, including 18 treated with dabrafenib/trametinib (58.1%) and 13 with vemurafenib/cobimetinib (41.9%); 58.1% were male, 41.9% were female and median age was 52 years. A significant decrease in SMA was observed after dabrafenib/trametinib and vemurafenib/cobimetinib treatments (P = 0.003 and P = 0.002, respectively). A significant decrease in FFM values was observed after dabrafenib/trametinib and vemurafenib/cobimetinib treatments (P = 0.003 and P = 0.002, respectively). Dose-limiting toxicity (DLT) was observed in 35.9% of the patients with sarcopenia. No significant difference was seen between the dabrafenib/trametinib and vemurafenib/cobimetinib groups in median progression-free survival (PFS) (11.9 vs. 7.3 months, respectively, P = 0.28) and in median overall survival (OS) (25.46 vs. 13.7 months, respectively, P = 0.41). Baseline sarcopenia was not significantly associated with PFS or OS (P = 0.172 and P = 0.326, respectively). We found a significant decrease in SMI values determined at 4-6 months compared to the values before treatment both in dabrafenib/trametinib and vemurafenib/cobimetinib groups. DLT was similar with both treatments. Baseline sarcopenia was not significantly associated with PFS or OS.

The increase of available synthetic cannabinoids poses an emerging public health threat worldwide. Synthetic cannabinoid use has been mainly reported in adolescent cases in pediatric practices; there are few reported cases involving infants affected by unintentional use. In this case report, we present the youngest age of synthetic cannabinoid bonzai exposure in the literature, discussing a 3-month-old child affected by exposure to the parents' use of bonzai in the home environment. Because unintentional exposure to synthetic cannabinoids like bonzai might be encountered, pediatric emergency teams should be aware of this condition and child protection teams should be informed of suspicions of child negligence and abuse as a part of the medical approach.

Objective: To evaluate the effect of nasal septal surgery on quality of life., Methods: A total of 49 patients who underwent septoplasty and/or inferior turbinate radiofrequency operations for nasal septal deviation and inferior turbinate hypertrophy were prospectively enrolled in the study. All patients completed the adult attention-deficit/hyperactivity disorder scale (ADHD scale) and Pittsburgh sleep quality index (PSQI) before and after septoplasty. Acoustic rhinometric measurements were also recorded., Results: Acoustic rhinometric measurements and PSQI showed statistically significant improvement after nasal surgery (P < 0.05), but no statistically significant difference was present between pre- and postoperative ADHD scores (P > 0.05)., Conclusion: Besides the functional improvement of septoplasty, a long-lasting improvement in the quality of life is observed in patients with that undergo this surgery.

Rationale: Increased titin-dependent cardiomyocyte tension is a hallmark of heart failure with preserved ejection fraction associated with type-2 diabetes mellitus. However, the insulin-related signaling pathways that modify titin-based cardiomyocyte tension, thereby contributing to modulation of diastolic function, are largely unknown., Objective: We aimed to determine how impaired insulin signaling affects titin expression and phosphorylation and thus increases passive cardiomyocyte tension, and whether metformin or neuregulin-1 (NRG-1) can correct disturbed titin modifications and increased titin-based stiffness., Methods and Results: We used cardiac biopsies from human diabetic (n=23) and nondiabetic patients (n=19), cultured rat cardiomyocytes, left ventricular tissue from apolipoprotein E-deficient mice with streptozotocin-induced diabetes mellitus (n=12-22), and ZSF1 (obese diabetic Zucker fatty/spontaneously hypertensive heart failure F1 hybrid) rats (n=5-6) and analyzed insulin-dependent signaling pathways that modulate titin phosphorylation. Titin-based passive tension was measured using permeabilized cardiomyocytes. In human diabetic hearts, we detected titin hypophosphorylation at S4099 and hyperphosphorylation at S11878, suggesting altered activity of protein kinases; cardiomyocyte passive tension was significantly increased. When applied to cultured cardiomyocytes, insulin and metformin increased titin phosphorylation at S4010, S4099, and S11878 via enhanced ERK1/2 (extracellular signal regulated kinase 1/2) and PKCα (protein kinase Cα) activity; NRG-1 application enhanced ERK1/2 activity but reduced PKCα activity. In apolipoprotein E-deficient mice, chronic treatment of streptozotocin-induced diabetes mellitus with NRG-1 corrected titin phosphorylation via increased PKG (protein kinase G) and ERK1/2 activity and reduced PKCα activity, which reversed the diabetes mellitus-associated changes in titin-based passive tension. Acute application of NRG-1 to obese ZSF1 rats with type-2 diabetes mellitus reduced end-diastolic pressure., Conclusions: Mechanistically, we found that impaired cGMP-PKG signaling and elevated PKCα activity are key modulators of titin-based cardiomyocyte stiffening in diabetic hearts. We conclude that by restoring normal kinase activities of PKG, ERK1/2, and PKCα, and by reducing cardiomyocyte passive tension, chronic NRG-1 application is a promising approach to modulate titin properties in heart failure with preserved ejection fraction associated with type-2 diabetes mellitus., (© 2018 American Heart Association, Inc.)

The psychological impact of relocation within and outside of a disaster region was examined in 541 survivors of the 2011 Van earthquake in Turkey at 16.5 months postdisaster. Relocation out of the region was determined by disaster-related property/financial losses and fear during the earthquake. Anticipatory fear of future earthquakes and less sense of control over life were the strongest predictors of posttraumatic stress disorder (PTSD) and depression symptoms. Relocation within the disaster region predicted PTSD but not depression. Dissatisfaction with emotional support received from close ones was significantly associated with depression, but it was associated with PTSD at a marginally significant level. Survivors who experienced more intense fear during the earthquake displayed higher levels of anticipatory fear in the long term, whereas avoidance of trauma reminders and fear-evoking situations sustained anticipatory fear of future earthquakes. These findings suggest that interventions that reduce fear and avoidance behaviors would help survivors overcome traumatic stress and depressive symptoms.

Purpose: The purpose of this study was to evaluate the efficiency and feasibility of dual-energy computed tomography (DECT) used in the diagnosis of cardiac contusion with the mildest blunt cardiac injury., Material and Methods: This study was performed between February 2014 and September 2015; a total of 17 consecutive patients (10 men and 7 women; median age, 51 years [range: 20-78]) were enrolled in the study. The DECT was performed within 48 hours of the trauma and a subsequent follow-up DECT was performed a little less than 1 year after the first examination. All examinations were analyzed on iodine map images by 2 experienced radiologists. Interobserver and intraobserver agreement was calculated. The correlation of initial troponin level, age, and sex with number of contusion areas in the left ventricle and complete recovery of contusion were measured., Results: The contusion areas were amorphous, with considerable variation in their size, shape, and density. Contusions were primarily located in the left free wall of the ventricle, the ventricular septum, and the apex, respectively. In 10 patients, contusion areas disappeared on follow-up examination. In 4 patients, the contusion areas decreased but were still present in the follow-up examination. The interobserver agreements were almost perfect with respect to the presence of cardiac contusion, the anatomic location of contusions, and the contusion areas (kappa values of 1.0, 1.0, and 0.9 for intraobserver agreement and 1.0, 1.0, and 1.0 for intraobserver agreement, respectively). Correlations were found between age of patients and complete recovery of contusion (P = 0.01)., Conclusions: Dual-energy computed tomography can show cardiac contusion and could be useful and feasible for the diagnosis and follow-up of blunt cardiac injuries. Dual-energy computed tomography is a new, user-independent, and valuable imaging technique.

Sirolimus is a mammalian target of the rapamycin, a protein kinase, which is responsible for inhibition of T cell and B cell proliferation. Sirolimus has side effects on lugs, and may cause cryptogenic organizing pneumonia, diffuse alveolar hemorrhage, lymphocytic pneumonitis, hypersensitivity pneumonitis, desquamative interstitial pneumonia, and pulmonary alveolar proteinosis. Diagnosis is based on the combination of clinical, radiological, histological, and pathological investigation. We report a case of diffuse alveolar hemorrhage in a 33-year-old, female renal transplant recipient. After discontinuation of sirolimus, radiological images and clinical condition of the patient got better. We also planned steroid therapy for 6 months by tapering the dosage slowly. After steroid therapy, full recovery of pulmonary functions achieved, and the patient is observed in our outpatient clinic with lack of any pulmonary symptoms.

There are published reports stating that some of the congenital metabolic diseases, such as lysinuric protein intolerance, multiple sulphatase deficiency, galactosemia, Gaucher disease, Pearson syndrome, and galactosialidosis, might lead to secondary hemophagocytic lymphohistiocytosis (HLH). However, to date, to our knowledge, the long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency has never been investigated among patients with HLH. Here, we report on a patient who was referred to our institution for a differential diagnosis of pancytopenia, liver failure, and rhabdomyolysis. The patient was diagnosed with HLH. Further investigation revealed an underlying diagnosis of the LCHAD deficiency. Our case was reported to contribute to the literature, as well as the HLH clinic, emphasizing the consideration of LCHAD deficiency, especially in 1 to 6 months' old infants with laboratory findings of hypoglycemia, metabolic acidosis, and elevated creatine kinase.

Purpose: Comparison of Frey syndrome rates following superficial parotidectomy and partial superficial parotidectomy for pleomorphic adenoma., Methods: Fifty patients diagnosed with pleomorphic adenoma and received surgical treatment at the Otolaryngology Department of Bagcilar Training and Research Hospital between January 2009 and October 2015 were reviewed retrospectively. The patients were specifically queried for Frey syndrome symptoms. The syndrome was investigated with Minor starch iodine test. The patients who underwent superficial parotidectomy were compared to those who underwent partial superficial parotidectomy in terms of Frey syndrome development and recurrence., Results: In the partial superficial parotidectomy group, Frey syndrome symptoms were edema and increased sweating and burning sensation on the face in 7 patients (21.9%, P = 0.735). In the superficial parotidectomy group, 5 patients exhibited edema (27.8%), 3 exhibited increased sweating (16.7%), and 5 exhibited burning sensation (27.8%). Minor test results were positive for 7 patients in the partial superficial parotidectomy group (21.8%) and 5 patients were positive (27.8%) in the superficial parotidectomy group. No recurrence was found in either group during the 5-year follow-up. No significant difference was found between 2 groups in terms of postoperative complications and recurrence., Conclusion: In terms of their effect on Frey syndrome development, there is no significant difference between partial superficial parotidectomy and superficial parotidectomy.

Objectives: To evaluate the demographics, risk factors, correlation between carbon monoxide (CO) level and clinical findings, and laboratory findings determining the prognosis and ischemic myocardial injury due to CO intoxication in patients admitted to pediatric emergency department., Materials and Methods: Six hundred seventy-four patients were admitted with CO intoxication between May 2007 and October 2009, 288 patients who required hospitalization were enrolled into the study prospectively., Results: Incidentally, 144 (50%) of the patients were evenly distributed as girls and boys. Their age ranged between 7 months and 17 years; mean age was 8.6 years. The mean CO level was 26.8. The high levels were detected regarding lactate in 199 (90.1%) patients, creatine kinase (CK)-MB in 130 (45.1%) patients, CK in 80 (27.8%) patients, cardiac Troponin I in 35 (17.2%) patients, and lactate dehydrogenase in 34 (15.7%) patients. There was a significant positive correlation when symptoms like syncope, loss of consciousness, and convulsion were compared with carboxyhemoglobin, lactate, CK, CK-MB, and lactate dehydrogenase levels (P < 0.05), whereas there was no correlation when compared with cardiac Troponin I (P > 0.05). To determine the accuracy of predicting severe CO intoxication, sensitivity of 52.6% and specificity of 85.7% were found in receiver operating characteristic analysis when the lactate level was 3.85 mmol/L, whereas sensitivity of 70.5% and specificity of 59.6% were found when the carboxyhemoglobin level was 27.1%. One hundred forty-six (%50.8) of the patients had normal electrocardiographic findings, whereas 135 (46.8%) had sinus tachycardia, 6 (2%) had right branch block, and 1 (0.34%) had atrioventricular block. In 34 patients who had high CK-MB and Troponin I levels, only sinus tachycardia was detected in electrocardiography, and there were no ST changes. Hyperbaric oxygen was necessary in 2 patients admitted with coma., Conclusions: In children admitted because of CO intoxication, the blood lactate levels may give more accurate information in terms of loss of consciousness and convulsion, lactate level could be taken as a measure of severe poisoning and may help to decide for hyperbaric oxygen treatment.

Purpose: To evaluate advanced oxidation protein products (AOPP) levels, superoxide dismutase (SOD) enzyme activity, and total sulfhydryl (TSH) levels in rabbit corneas after different corneal collagen cross-linking (CXL) methods., Methods: Eighteen eyes of 9 adult New Zealand rabbits were divided into 3 groups of 6 eyes. The standard CXL group was continuously exposed to UV-A at a power setting of 3 mW/cm for 30 minutes. The accelerated CXL (A-CXL) group was continuously exposed to UV-A at a power setting of 30 mW/cm for 3 minutes. The pulse light-accelerated CXL (PLA-CXL) group received UV-A at a power setting of 30 mW/cm for 6 minutes of pulsed exposure (1 second on, 1 second off). Corneas were obtained after 1 hour of UV-A exposure, and 360-degree keratotomy was performed. SOD enzyme activity, AOPP, and TSH levels were measured in the corneal tissues., Results: Compared with the standard CXL and A-CXL groups (133.2 ± 8.5 and 140.2 ± 6.2 μmol/mg, respectively), AOPP levels were found to be significantly increased in the PLA-CXL group (230.7 ± 30.2 μmol/mg) (P = 0.005 and 0.009, respectively). SOD enzyme activities and TSH levels did not differ between the groups (P = 0.167 and 0.187, respectively)., Conclusions: CXL creates covalent bonds between collagen fibers because of reactive oxygen species. This means that more oxygen concentration during the CXL method will produce more reactive oxygen species and, thereby, AOPP. This means that in which CXL method occurs in more oxygen concentration that will produce more reactive oxygen species and thereby AOPP. This study demonstrated that PLA-CXL results in more AOPP formation than did standard CXL and A-CXL.

Objective: Our objective was to demonstrate the effects of platelet-rich fibrin (PRF) for the healing of acute ear drum perforation., Methods: Thirty-two patients with acute traumatic ear drum perforations were randomly separated into 2 groups. In group 1 (n = 14), PRF was used for the repair of ear drum perforation; in group 2 (n = 18), we did not make any intervention., Results: At initial inspection, perforation sizes were measured as 10.93 ± 3.58 mm in group 1 and 10.05 ± 4.02 mm in group 2. After 1 month, perforation sizes were 1.35 ± 2.53 mm in group 1 and 4.44 ± 3.34 mm in group 2 (P < 0.01). In the study group, the rate of ear drum closure was 64.3% and in the control group it was 22.2% (P < 0.05)., Conclusion: Here we found that PRF is a biomaterial that quickens the healing of ear drum which is autogenous and simply prepared.

Background: This randomized, double-blind study was designed to assess the effect of perioperative remifentanil with controlled hypotension on intraoperative bleeding, postoperative edema, and ecchymosis., Methods: Fifty-two patients undergoing rhinoplasty were divided into 2 groups. The remifentanil group received 1 µg · kg(-1) intravenously as a bolus before induction of anesthesia, 0.5 to 1 µg · kg(-1) · h(-1) by continuous intravenous infusion during the operation. After anesthesia induction with propofol (2-3 mg · kg(-1)) and fentanyl (1-15 µg · kg(-1)), muscle relaxation was achieved with rocuronium (0.45-0.90 mg · kg(-1)). Mean arterial pressure was maintained at 50 to 60 mm Hg in controlled hypotensive anesthesia achieved using remifentanil infusion. Perioperative hemodynamics and bleeding; early postoperative pain and agitation scale; postoperative first, third, and seventh day edema; and ecchymosis were evaluated. Edema and ecchymosis were evaluated using graded scale from 0 to 4., Results: Remifentanil reduced mean arterial pressure during the entire operative period and the first 30 minutes postoperatively (P < 0.05 for these comparisons). Intraoperative bleeding also decreased (P < 0.001). There was a significant decrease in edema in both upper and lower eyelid edema on the first and third days in the remifentanil group, although this difference was not detected on the seventh day (P(1upper) = 0.000, P(1lower) = 0.000, P(3upper) = 0.008, and P(3lower) = 0.002). Ecchymosis decreased significantly in both upper and lower eyelids on the first, third, and seventh days in the remifentanil group (P(1upper) = 0.000, P(3upper) = 0.000, P(3upper) = 0.002, P(3lower) = 0.002, P(7upper) = 0.049, and P(7lower) = 0.038). There were no differences in postoperative pain and agitation between 2 groups., Conclusions: Remifentanil with controlled hypotension may reduce edema and ecchymosis of the upper and lower eyelids, by reducing mean arterial pressure and amount of bleeding in rhinoplasty.

Background: The objectives of this study were to examine the prevalence and risk of pressure ulcers (PrUs) among hospitalized patients 65 years or older in a university hospital setting and to assess the potential for prevention and healing in that population., Methods: The retrospective study conducted at the general medicine departments of Ege University Hospital in Izmir, Turkey, included 209 patients (115 females, 94 males) 65 years or older, who had been admitted to the hospital for a variety of reasons between April 1, 2011, and October 1, 2011. The following tools were used to collect data: a data collection form to identify the sociodemographic and medical characteristics of the patients, the Braden Risk Assessment Scale to assess the risk of PrUs, and a form to monitor PrUs, which included the site of the PrU, the category, and the PUSH (Pressure Ulcer Scale for Healing) score, a tool for tracking changes in PrUs status applied at weekly intervals., Results: The mean patient age was 73 (6.4) years. The prevalence of PrUs was 5.8% during the hospital stay. Pressure ulcers appeared most frequently in the ischeal tuberosity area (40%), and 45.2% of all PrUs observed were category II. The comorbidities of the patients who had PrUs were as follows: rheumatoid arthritis, 40% (n = 5); acute renal failure, 24% (n = 3); multiple myeloma, 8% (n = 1); chronic renal failure, 8% (n = 1); pneumonia, 8% (n = 1); and acute lymphoblastic leukemia, 8% (n = 1)., Conclusions: Pressure ulcers are a common healthcare complication in the older adult population, with potentially severe consequences. The most important intervention that healthcare professionals can make to reduce PrUs is to determine and address risk factors.

Cervical necrotizing fasciitis (CNF) is a rare, rapidly advancing infection that involves the skin, the subcutaneous fibrofatty tissue, as well as the superficial and deep fascia and can cause life-threatening complications. The most frequent initiating factors in the head and neck region are a primary odontogenic infection, a peritonsillar infection, as well as posttraumatic or iatrogenic skin and mucosal injuries. Necrotizing fasciitis (NF) can expand within hours, and the reported mortality rate is up to 75% with delay interference. If the patients have any risk factors, poor prognosis can be seen. In this study, 1 patient with CNF with a history of peritonsillar infection and 2 patients with CNF who had a history of odontogenic infection with spreading to the temporal region and the mediastinum were described, with information of the literature and a clinical experience that was gained from 5 patients with NF who were seen at our clinic in the recent year, despite the fact that CNF was not seen up to last year. None of the patients had any risk factors. One of them had a worse clinical state with ascending infection to the temporal region, cranial nerve paralysis, and descending necrotizing mediastinitis, but he recovered from NF. After the oral intake began, dyspnea due to aspiration was seen and he died because of sepsis and multiorgan dysfunction. We aimed to attract attention to the importance of dental pathologies and increased mortality in a healthy patient.

Introduction: Idiopathic Sudden sensorineural hearing loss (ISSNHL) is a common otologic emergency. Recently, the cause of ISSNHL, which is still unclear, has been focused on chronic inflammation. Neutrophil-to-lymphocyte ratio (NLR) is a new and quick inflammatory marker, which is being measured routinely in CBC tests without any cost. We aimed to investigate the relationship between ISSNHL and inflammation by using NLR., Materials and Method: Forty-seven patients diagnosed with ISSNHL and 45 age- and sex-matched healthy subjects were enrolled in the study. An automated blood cell counter was used for NLR measurements. The hearing assessments of the patients were carried out by an audiometer, and audiometric patterns were assessed initially and after 1 month of the treatment. All the patients were treated with prednisone in the dose of 1 mg/kg per day, with a progressive dose reduction maintained for at least 2 weeks. Then, the patients were divided into 2 groups as " recovered" and "unrecovered" according to their response to the treatment., Results: The mean NLR, neutrophil, and lymphocyte values in patients with ISSNHL were significantly higher than the control group (p < 0.001, p < 0.001, and p = 0.004, respectively). In addition, NLR levels were higher in unrecovered patients compared with the recovered ones (p < 0.001)., Conclusion: This is the first study investigating the relationship between NLR levels and ISSNHL and its prognosis. While evaluating ISSNHL, determining NLR should not be overlooked as a quick and reliable indicator for predicting the diagnosis and the prognosis of the disease.

Objective: We aimed to evaluate the relationship between sleep quality and a dipping-nondipping pattern in normotensive individuals., Materials and Methods: Our study was carried out on 100 normotensive individuals; 50 of these individuals had a dipping pattern and 50 had a nondipping pattern, and were chosen from among patients in whom ambulatory blood pressure monitoring was applied before for any reason. All study participants underwent the Pittsburgh Sleep Quality Index survey to evaluate sleep disturbances., Results: The overall scores and all the components of the Pittsburgh Sleep Quality Index scores were significantly higher in the nondipper normotensive group compared with the dipper normotensive group., Conclusion: In conclusion, the nondipping blood pressure pattern appears to be associated with poor sleep quality not only in hypertensive patients but also in normotensive healthy individuals. When evaluating patients with poor sleep quality, the possibility that they may have a nondipping pattern even if they are normotensive should be kept in mind.

The hypoglossal nerve appears typically between the internal carotid artery and internal jugular vein and down in the lateral groove between these 2 anatomical structures on to the right common carotid artery bifurcation. In this case report, we presented a patient that was operated on for laryngeal carcinoma, and abnormal navigation of hypoglossal nerve was observed during the neck dissection.

We aimed to examine the prevalence of cerebellar tonsil ectopia and Chiari 1 malformation in sensorineural hearing loss (SHL) that has, to the best of our knowledge, not been studied previously. Magnetic resonance imaging records of 166 subjects with SHL and 50 controls without known otologic disturbances were included in the study. A tonsils descent more than 2 mm was assumed as cerebellar ectopia, and a descent equal to or more than 5 mm was assumed as Chiari 1 malformation. A tonsil descent group was also formed by summation of both groups. Transverse diameters of bilateral intracranial vertebral arteries and transverse sinuses were also measured, and all parameters were analyzed using appropriate statistics. A significant difference of frequencies of Chiari 1, ectopia, and tonsil descent was detected between patients and controls. In comparison of cerebellar ectopia and Chiari 1 groups, SHL did not show any significant difference. The left lateral sinus diameter showed positive correlation with tonsil descent. There was no significant correlation for the diameters of other vessels. A powerful correlation was detected between SHL and age. In addition, right and vertebral artery diameters showed positive correlations with age. Chiari 1 malformation and cerebellar ectopia showed an association with SHL. These patients should also be evaluated for otologic disturbances. Further high-resolution magnetic resonance imaging studies to explain the exact cause of this currently unknown association seems required.

Hydrogen peroxide solutions are often used in daily life as a household disinfectant and in cosmetic products and are therefore a common source of intentional poisonings, especially for children. When ingested in small amounts, it may cause severe central nervous system damage as a result of arterial emboli like our case. The benefit of hyperbaric oxygen treatment in this situation is known, but the neurologic deficits of our case did not improve with this method and finally brain death occurred. This is may be related by the timing of treatment after the event. We would like to emphasize that every clinician must be aware of the dangers of hydrogen peroxide ingestion and hyperbaric oxygen treatment may be of benefit if it is performed immediately.

Aim: To investigate whether α-tocopherol and ascorbic acid have effect on the suppression of inflammation in the early postoperative period after open heart surgery., Methods: A total of 59 patients who had undergone cardiopulmonary bypass (CPB) in the Cardiovascular Surgery Department of a tertiary center between June 2008 and December 2008 were retrospectively investigated. The study group consisted of 34 patients (25 men, 9 women) to whom ascorbic acid (500  mg/day) and α-tocopherol (300  mg/day) were administered on the day of operation (0th day) and the first four consecutive postoperative days. In contrast, 25 controls (20 men, 5 women) received no additional anti-inflammatory medications. The two groups were compared in terms of demographics, blood parameters such as C-reactive protein (CRP) and white blood cell (WBC) count, and durations of cross-clamp and CPB., Results: In the control group, CRP levels were found to be increased on the first postoperative day (P < 0.001) and CRP levels were correlated with triglyceride levels on the day of operation (P = 0.009) and the first postoperative day (P = 0.021). On the second postoperative day WBC count was found to be decreased (P = 0.008) and correlated with glucose level (P < 0.005). In the study group, CRP levels were found to be inversely correlated with serum high-density lipoprotein (HDL) (P = 0.049) on the first postoperative day and directly correlated with triglyceride levels on the second postoperative day (P = 0.017). Blood glucose levels were found to be increased on the first postoperative day (P = 0.021) and a correlation was detected between WBC count on the fourth postoperative day and doses of ascorbic acid and α-tocopherol (P = 0.027)., Conclusion: Suppression of the systemic inflammatory response to CPB is a double-edged sword and whether this suppression aids in the attenuation of morbidity and mortality is obscure. In this respect, ascorbic acid and α-tocopherol seem to display some anti-inflammatory effect, but further studies are necessary to reveal the actual therapeutic potential and the complex mechanism related to biochemical and inflammatory parameters.

Necrotizing soft-tissue infection (NSTI) is a bacterial infection with necrosis of the cutaneous, subcutaneous tissue and fascia with sparing of the underlying muscle. The most frequent initiating factor reported, for necrotizing fasciitis, in the head and neck region is a primary odontogenic infection or postextraction infection, abrasion, and laceration of the face or scalp. Necrotizing fasciitis can progress rapidly to systemic toxicity and even death if not promptly diagnosed and treated. If the patient has any risk factors, this can worsen the prognosis. In this study, 2 cases of NSTI with dental pathology history (one with the spreading to mediastinum and the other spreading to suprahyoid) were discussed with a review of the literature. One of the cases had diabetes mellitus, but interestingly, she had a better prognosis, and she was discharged asymptomatic. In addition, the other case had no any risk factors, but he had a worse clinical cranial nerve paralysis (a rare complication of NSTI) and died. As a conclusion, despite the intensive therapy, large debridement, and antibiotics with large spectrum, the delay in the patient's diagnosis and treatment increased mortality. We aimed to attract attention to the importance of dental pathologies and early diagnosis.

Objectives: Storage of human milk by freezing has been recommended for long-term storage. The present study analyzed the bactericidal activity of human milk on Escherichia coli and Pseudomonas aeruginosa and determined the changes in bactericidal activity following freezing at -20°C and -80°C for 1 month and 3 months., Methods: Forty-eight milk samples were collected from 48 lactating mothers. Each sample was divided into 10 aliquots. Two of the samples were processed immediately and the others were stored at both -20°C and -80°C until analysis after 1 month and 3 months of freezing., Results: All of the fresh milk samples showed bactericidal activity against E coli and P aeruginosa. Freezing at -20°C for 1 month did not cause statistically significant alteration in bactericidal activity (P > 0.017), whereas storage for 3 months lowered the degree of bactericidal activity significantly (P < 0.017) against E coli. Bactericidal activity was protected when the samples were stored at -80°C. There was no statistically significant difference in the bactericidal activity of human milk against E coli between freezing at -20°C and -80°C for 1 month (P > 0.017); however, when milk was stored for 3 months, -80°C was significantly more protective (P < 0.017). Freezing at -20°C and -80°C for 1 month and 3 months did not cause any significant change in bactericidal activity against P aeruginosa (P > 0.05)., Conclusions: Storage by freezing at -80°C is more appropriate to keep bactericidal capacity of stored human milk >1 month if affordable and available, especially in intensive care settings.