Traumatic brain injury and palliative care:a retrospective analysis of 49 patients receiving palliative care during 2013–2016 in Turkey

Traumatic brain injury（TBI）,which is seen more in young adults,affects both patients and their families.The need for palliative care in TBI and the limits of the care requirement are not clear.The aim of this study was to investigate the length of stay in the palliative care center（PCC）,Turkey,the status of patients at discharge,and the need for palliative care in patients with TBI.The medical records of 49 patients with TBI receiving palliative care in PCC during 2013–2016 were retrospectively collected,including age and gender of patients,the length of stay in PCC,the cause of TBI,diagnosis,Glasgow Coma Scale score,Glas gow Outcome Scale score,Karnofsky Performance Status score,mobilization status,nutrition route（oral,percutaneous endoscopic gastrostomy）,pressure ulcers,and discharge status.These patients were aged 45.4 ± 20.2 years.The median length of stay in the PCC was 34.0 days.These included TBI patients had a Glasg ow Coma Scale score ≤ 8,were not mobilized,received tracheostomy and percutaneous endoscopic gastrostomy nutrition,and had pressure ulcers.No difference was found between those who were discharged to their home or other places（rehabilitation centre,intensive care unit and death） in respect of mobilization,percutaneous endoscopic gastrostomy,tracheostomy and pressure ulcers.TBI patients who were followed up in PCC were determined to be relatively young patients（45.4 ± 20.2 years） with mobilization and nutrition problems and pressure ulcer formation.As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit,provision of palliative care services should be integrated with clinical applications.

Adipose-derived stem cells in the treatment of hepatobiliary diseases and sepsis

Determination of the mesenchymal stem cells is one of the greatest and most exciting achievements that tissue engineering and regenerative medicine have achieved.Adipose-derived mesenchymal stem cells(AD-MSC)are easily isolated and cultured for a long time before losing their stem cell characteristics,which are self-renewal and pluripotency.AD-MSC are mesenchymal stem cells that have pluripotent lineage characteristics.They are easily accessible,and the fraction of stem cells in the adipose tissue lysates is highest among all other sources of mesenchymal stem cells.It is also HLA-DR negative and can be transplanted allogenically without the need for immunosuppression.These advantages have popularized its use in many fields including plastic reconstructive surgery.However,in the field of hepatology and liver transplantation,the progress is slower.AD-MSC have the potential to modulate inflammation,ameliorate ischemia-reperfusion injury,and support liver and biliary tract regeneration.These are very important for the treatment of various hepatobiliary diseases.Furthermore,the anti-inflammatory potential of these cells has paramount importance in the treatment of sepsis.We need alternative therapeutic approaches to treat end-stage liver failure.AD-MSC can provide a means of therapy to bridge to definitive therapeutic alternatives such as liver transplantation.Here we propose to review theoretic applications of AD-MSC in the treatment of hepatobiliary diseases and sepsis.

Comparison of Nasal and Frontal BIS Monitoring in Neurosurgery: Does the Site of Sensor Placement Affect the BIS Values?

Background and Goal of Study: Intraoperative awareness is a serious but preventable complication of general anaesthesia. Bispectral index (BIS) is the most widely used method monitoring anaesthesia depth. BIS monitoring requires attachment of forehead sensors, which poses a challenge when the surgical field involves the forehead. We aimed to compare the gold standard forehead position of BIS sensors with an alternative position across the nasal dorsum for neurosurgical procedures. Materials and Methods: After ethical committee approval and informed consent were obtained, 62 patients were enrolled in this prospective observational study. Frontal and nasal BIS values were compared in all patients. Results and Discussion: The mean BIS value from frontal versus nasal sensors was 49 ± 22 and 49 ± 21 respectively (n: 62). These values were statistically correlated (ICC 0.78, p < 0.001) indicating that nasal BIS measurement does not present a disadvantage for routine use when needed. Conclusion: Our data reveal that for measuring anesthesia depth, BIS sensor placement on the nasal dorsum shows comparable efficiency in comparison to standard frontal

Plasma Concentrations of Some Trace Element and Heavy Metals in Patients with Metastatic Colon Cancer

Purpose: It is well known that trace elements and heavy metals play a significant role in human health and disease. These elements play an important role in different metabolic pathways of cells and tissues. Trace element deficiency or excess is implicated in the development or progression of some cancers. We present a study which investigates serum/ plasma levels of trace-heavy elements in metastatic colon cancer patients and healthy subjects. Methods: Blood samples were collected from 29 healthy subjects and 40 patients with metastatic colon cancer in Oncology Department of Medical School of Yuzuncu Yil University. In both groups, the serum levels of copper (Cu), magnesium (Mg), lead (Pb), chromium (Cr), zinc (Zn) selenium (Se), manganese (Mn), and cadmium (Cd) were determined. Results: Higher levels of Cu, Mg, Pb, Cr, Zn, Mn and Cd were seen in patients with metastatic colon cancer compared to healthy subjects and these findings were statistically significant (p 0.05). Se levels were noted to be lower in patients with colon cancer in comparison to healthy subjects and this finding was also statistically significant (p 0.05). Conclusions: According to our findings there was significant diffence in trace elements and heavy metals levels between healthy subjects and metastatic colon cancer patients. Therefore heavy metal and trace elements may have prognostic significance in complex disorders including colon cancer. However, further comprehensive studies are needed in order to advance our understanding of the relationship between heavy metal and trace elements and their role in cancers.

Effect of pH,lactate,electrolyte,and strong ion difference variability on prediction of intensive care unit mortality:A retrospective study

Objective:To investigate the effect of the variability of Nas,Cls,Ks,lactate values and sodium effect(NaEffect),chloride effect(ClEffect),non-lactate strong ion difference(SIDnl)values calculated according to Stewart’s approach on predicting intensive care unit(ICU)mortality.Methods:The study was conducted on 1539 patients,retrospectively.Serum Na(Nas),serum Cl(Cls),serum K(Ks),serum Ca(Cas),serum Mg(Mgs),lactate,pH values and SIDnl,NaEffect,ClEffect,APACHEⅡ(first,last),and SOFA(first,last)scores were recorded.Radiometer ABL 800(Denmark)was used for blood gas analysis.The variability of each parameter was calculated.The effect of variability of each parameter on 30-day ICU mortality was analyzed.Results:The variability of lactate(P<0.001,OR=0.580,95%CI=0.505-0.652),pH(P=0.001,OR=0.004,95%CI=0.000-0.104),NaEffect(P<0.001,OR=0.550,95%CI=0.378-0.592),Ks(P<0.001,OR=0.385,95%CI=0.244-0.565)values were protective factors of ICU mortality and Cls value was a risk factor(P=0.004,OR=1.095,95%CI=1.024-1.164).Variability of ClEffect,SIDnl values did not affect ICU mortality.Conclusions:The variability of electrolytes is important.Electrolyte,effects,and lactate variability can guide treatment and fluid applications in ICU.

Intensive care outcomes of refugee patients in Turkey between 2013 and 2019: A retrospective descriptive study

Objectives:To assess the outcomes of the intensive care of Syrian refugees under temporary protection (SRUTP). Methods: The sample of the study was composed of 110 SRUTP patients who were treated at a tertiary intensive care unit (ICU) between 2013 and 2019 in Istanbul, Turkey. Baseline information and clinical data of the patients were collected by scanning the hospital's electronic database and clinical decision support system. Results:The mean length of ICU stay was 97.6 (36.3-187.8) h. Among the patients, 71 (64.5%) had comorbid diseases, and ICU mortality was 40%. The median cost of health care for each patient was 2144 (1060-4471) USD, and the total health care cost of all patients was 534012USD. Conclusions: Use of vasoactive drug, hemodialysis application, and low Glasgow Coma Scale scores are independent risk factors of the mortality. More researches are needed to clearly reveal the health and cost consequences of war.

Female infertility and laparoscopic surgery: A series of 415 operations at the Yaounde Gyneco-Obstetric and Pediatric Hospital, Cameroon

Objective: To describe the practice of laparoscopic surgery in the treatment of infertility at the Yaoundé Gyneco-Obstetrics and Pediatric Hospital. Materials and Methods: This was an observational study with retrolective data collection. All patients who underwent laparoscopy for infertility with a complete file were recruited. Data were collected on a pre-established form and analyzed with Microsoft Excel 2007 software. Results: Six hundred and thirty-three women, representing 6.9% of gynecologic operations, underwent laparoscopic surgery during the study period. Infertility accounted for 69.8% (442 cases) of the indications. Four hundred and fifteen files were analyzed. The commonest intraoperative findings were: tubo-peritoneal adhesions (71.6%), hydrosalpinx with distal tubal occlusion (41.5%), peri-hepatic adhesions (22.4%), uterine fibroids (20.2%) and tubal phimosis (14.0%). Adhesiolysis, neosalpingostomy and fimbrioplasty were the commonest surgical gestures. At the end of the procedure, the best tube was staged as favorable in 57.6% of our patients. A complication rate of 4.3% was observed. Conclusion: Infertility is the main indication for laparoscopic surgery in our setting. The main operative findings are tubo-peritoneal adhesions and hydrosalpinx. The most practiced tubal surgical gesture is neosalpingostomy. Half of the recruited women have a favorable stage for the best tube. The complication rate is low.

Effect of age on computed tomography findings:Specificity and sensitivity in coronavirus disease 2019 infection

BACKGROUND Coronavirus disease 2019(COVID-19)is a pandemic caused by the severe acute respiratory syndrome coronavirus in 2019.Although the real-time reverse transcription PCR test for viral nucleic acids is the gold standard for COVID-19 diagnosis,computed tomography(CT)has grown in importance.AIM To evaluate the sensitivity and specificity of thoracic CT findings of COVID-19 pneumonia according to age groups.METHODS PCR and CT results from 411 patients were reviewed.The diagnosis of COVID-19 pneumonia was made by three radiologists.Lymphadenopathy,pericardial effusion,pleurisy,pleural thickening,pleural effusion,location features of the lesions,ground glass,consolidation,air bronchogram,vascular enlargement,bronchial dilatation,halo finding,inverted halo sign,nodularity,air bubble,subpleural band(curvilinear density),reticular density,crazy paving pattern,and fibrosis findings were recorded.The patients were divided into nine groups by decades while calculating the sensitivity,specificity,and diagnostic efficacy for CT positivity.RESULTS The mean age of the cases was 48.1±22.7 years.The CT finding with the highest diagnostic power was ground glass.Vascular enlargement and bronchial dilatation followed ground glass.Pericardial effusion was the finding with the lowest diagnostic accuracy.The incidence of lymphadenopathy,pleurisy,pleural thickening,peripheral localization,bilateral,ground glass,vascular enlargement,bronchial dilatation,subpleural band,reticular density,crazy paving appearance,and fibrosis all increased increase significantly with age in patients with positive real-time reverse transcription PCR test.CONCLUSION There are few publications comparing sensitivity and specificity of thoracic CT findings according to age.In cases of COVID-19 pneumonia,there is an increase in the variety and frequency of CT findings with age,and parallel to this the sensitivity and specificity of the findings increase.COVID-19 cases in the pediatric age group have fewer lung findings than adults,and this situation decreases the diagnostic value of CT in pediatric patients.

Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Carotid cavernous sinus fistulas are abnormal communications between the carotid system and the cavernous sinus. Several classification schemes have described carotid cavernous sinus fistulas according to etiology, hemodynamic features, or the angiographic arterial architecture. Increased pressure within the cavernous sinus appears to be the main factor in pathophysiology. The clinical features are related to size, exact location, and duration of the fistula, adequacy and route of venous drainage and the presence of arterial/venous collaterals. Noninvasive imaging (computed tomography, magnetic resonance, computed tomography angiography, magnetic resonance angiography, Doppler) is often used in the initial workup of a possible carotid cavernous sinus fistulas. Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of treatment for these lesions. The endovascular approach has evolved as the mainstay therapy for definitive treatment in situations including clinical emergencies. Conservative treatment, surgery and radiosurgery constitute other management options for these lesions.

Acute right lower abdominal pain in women of reproductive age:Clinical clues

AIM: To study possible gynecological organ pathologies in the differential diagnosis of acute right lower abdominal pain in patients of reproductive age.

Protective effects of intravenous anesthetics on kidney tissue in obstructive jaundice

AIM: To evaluate the protective effects on kidney tissue of frequently used intravenous anesthetics (ketamine, propofol, thiopental, and fentanyl) in rats with obstructive jaundice.

Effect of laparoscopic abdominal surgery on splanchnic circulation: Historical developments

With the developments in medical technology and increased surgical experience, advanced laparoscopic surgical procedures are performed successfully. Laparoscopic abdominal surgery is one of the best examples of advanced laparoscopic surgery (LS). Today, laparoscopic abdominal surgery in general surgery clinics is the basis of all abdominal surgical interventions. Laparoscopic abdominal surgery is associated with systemic and splanchnic hemodynamic alterations. Inadequate splanchnic perfusion in critically ill patients is associated with increased morbidity and mortality. The underlying pathophysiological mechanisms are still not well understood. With experience and with an increase in the number and diversity of the resulting data, the pathophysiology of laparoscopic abdominal surgery is now better understood. The normal physiology and pathophysiology of local and systemic effects of laparoscopic abdominal surgery is extremely important for safe and effective LS. Future research projects should focus on the interplay between the physiological regulatory mechanisms in the splanchnic circulation (SC), organs, and diseases. In this review, we discuss the effects of laparoscopic abdominal surgery on the SC.

Does the intrathecal propofol have a neuroprotective effect on spinal cord ischemia?

The neuroprotective effects of propofol have been confirmed. However, it remains unclear whether intrathecal administration of propofol exhibits neuroprotective effects on spinal cord ischemia. At 1 hour prior to spinal cord ischemia, propofol（100 and 300 μg） was intrathecally administered in rats with spinal cord ischemia. Propofol pre-treatment greatly improved rat pathological changes and neurological function deficits at 24 hours after spinal cord ischemia. These results suggest that intrathecal administration of propofol exhibits neuroprotective effects on spinal cord structural and functional damage caused by ischemia.

Anti-inflammatory efficiency of levobupivacaine in an experimental colitis model

AIM:To investigate the efficiency of levobupivacaine in treating experimentally induced colitis in rats.METHODS:Colitis was induced by trinitrobenzene sulfonic acid and ethanol in 30 rats under general anesthesia,and 10 rats were used as a sham group.Subsequent to induction of colitis,rats were divided into three groups;budesonide group received 0.1 mg/kg budesonide,levobupivacaine group received 10 mg/kg levobupivacaine and saline group received 1 mL saline solution via rectal route for 7 d.In the sham group,only routine rectal catheterization was performed without use of any material.At the end of 7 d,laparotomy and total colectomy were performed for histopathological ex-amination in all rats and blood samples were drawn for measurement of tumor necrosis factor(TNF)-αand interleukin(IL)-6 following cardiac puncture.Macroscopic and microscopic evaluations of the specimens were performed by a pathologist blinded to group assignment of the rats.RESULTS:Weight loss(P=0.016)and macroscopic examination scores(P=0.001)were significantly higher in saline group than others.Histopathological scoring was comparable between all colitis groups(P=0.350).There was no significant difference in TNF-αlevels and IL-6 levels(P=0.150).CONCLUSION:The significant improvement in macroscopic scores suggests that levobupivacaine may have topical anti-inflammatory effects in an experimental colitis model;however,this finding was not supported by microscopic findings.

Anesthetic management of the SRS^(TM) endoscopic stapling system for gastro-esophageal reflux disease

The SRS TM Endoscopic Stapling System(Medigus,Tel Aviv,Israel) is a new tool capable of creating a totally endoscopic fundoplication,combined with an endoscope,endoscopic ultrasound and a surgical stapler.SRS TM endoscopic stapling for gastro-esophageal reflux disease is a minimally invasive,outpatient procedure,which requires general anesthesia with positive-pressure ventilation.Keeping the patient on positive endexpiratory pressure(PEEP) may minimize the pressure gradient between the esophagus and the mediastinum,as well as help to prevent air from leaking around the screws and causing pneumomediastinum.In addition,in patients with hiatal hernia,higher PEEP levels may be required to increase intra-thoracic pressure and to force the stomach to slide into the abdomen for ease of endoscopy.We advise smoother emergence from anesthesia,taking precautions for retching,postoperative nausea and vomiting(PONV),while coughing and gagging during extubation and PONV may affect the success of the procedure.Total intravenous anesthesia with propofol and remifentanil seems to be a good choice for these reasons.

Effect of abdominal trauma on hemorrhagic shock-induced acute lung injury in rats

TO evaluate the effects of abdominal trauma on hemorrhagic shock-induced acute lung injury in rats. METHODS： Five groups were allocated （n = 8） in the study. Group Ⅰ was taken as the control group, group Ⅱ as the hemorrhagic shock group, group Ⅲ as hemorrhagic shock ＋ laparotomy, group Ⅳ as hemorrhagic shock ＋ splenectomy and group V as splenectomy ＋ omentectomy ＋ hemorrhagic shock group. Hemorrhagic shock was induced by drawing blood and reducing mean arterial pressure （MAP） to 40 mmHg within 10 min. After a hypotensive period of 1 h, animals were resuscitated. Bronchoalveolar lavage （BAL） was performed to recover cells from the alveolar space with 40 mL of BAL fluid after resuscitation malondialdehyde （MDA） and L-γ-glutamyl-L-cysteinylglycine （GSH） levels were measured in serum, erythrocytes and lung tissue. RESULTS： Serum, erythrocyte, lung tissue MDA and GSH levels were significantly increased in hemorrhagic shock groups Ⅱ-Ⅴ （P 〈 0.05）. Lymphocyte, neutrophil and alveolar macrophage counts in BAL fluid indicated a significant difference between control and shock groups （P 〈 0.05）. CONCLUSION： The degree of trauma increases hemorrhagic shock-induced acute lung injury.

Prognostic Signification of Admission Hyperglycemia among Acute Stroke Patients in Intensive Care Units in Kinshasa,the Democratic Republic of the Congo

BACKGROUND AND AIM: Although admission hyperglycemia has been reported to be associated with unfavorable outcomes in acute stroke, little is known about this association in sub-Saharan Africa. Therefore, the aim of the present study was to assess the prognostic significance of admission hyperglycemia in the acute phase of stroke in Congolese patients. METHODS: In a multicenter prospective cohort study, consecutive patients with acute stroke were examined in 5 Emergency Rooms or Intensive Care Units of Kinshasa between July 15th, 2017 and March 15th, 2018. The severity of stroke was assessed at admission using the Glasgow Coma Scale. Stress hyperglycemia was defined as random blood glucose levels at admission > 140 mg/dL in patients without known type 2 diabetes mellitus (T2DM). The endpoint was 10-day all-cause in-hospital mortality. Survival (time-to-death) curves were built using the Kaplan Meier methods. Cox proportional analysis was used to identify predictors of 10-day all-cause in-hospital mortality. The predictive performance of blood glucose level to predict 10-day all-cause in-hospital mortality was assessed using ROC curve analysis. RESULTS: Out of 194 patients (mean age 58.7 ± 13.1 years;64% males, 74.7% light to moderate stroke severity;63.4% ischemic stroke) enrolled, 106 (54.6%) had admission hyperglycemia with 77 (72.6%) having stress hyperglycemia. Ninety four deaths (48.5%);mortality rate of 6 deaths per 100 person-days (95%CI 2.7 - 9.3) occurred during a median follow up time 6 (5 - 7) days equivalent to 1542 person-days. Independent predictors of 10-day all-cause in-hospital mortality were admission hyperglycemia regardless of diabetes status (aHR 3.77;95%CI 1.92 - 7.42;p < 0.001), GCS - 5.23;p = 0.001) and non-use of mechanical ventilation (aHR 1.97;95%CI 1.05 - 3.70;p = 0.034). Blood glucose concentrations (AUC 0.743;95%CI 0.672 - 0.814) had a better predictive performance for 10-day all-cause in-hospital mortality with an optimal value of 154 mg/dL (sensitivity 76.6% and specificity 70%). CONCLUSION: More than half of critically ill stroke patients exhibit admission hyperglycemia that impacts negatively on their survival in the acute phase highlighting thus the need for a better blood glucose control to improve outcomes.

Anesthetic management of a child with Cornelia de Lange Syndrome undergoing open heart surgery:A case report

BACKGROUND Cornelia de Lange syndrome(CdLS)is a congenital multisystemic genetic disorder.The expected lifespan of children with this disorder has been prolonged in parallel with the advances in medicine in recent years.However,they still more frequently undergo cardiac surgery.There are some challenges for clinicians when faced with CdLS patients.We present the perioperative management of a child with CdLS undergoing open-heart surgery.CASE SUMMARY Severe pulmonic and subpulmonic valvular stenosis,enlargement of the right side of the heart,mild tricuspid regurgitation,atrial septal defect,and patent ductus arteriosus were diagnosed in a 14-month-old boy with manifested cyanosis,developmental delay,and malnutrition.Attempted balloon valvuloplasty was unsuccessful due to a severe stenotic pulmonary valve,therefore it was decided to perform an open surgical repair.Following a successful and uncomplicated intraoperative course,the patient was extubated on postoperative day 5,and adrenalin and dopamine infusions were gradually decreased and stopped on postoperative days 6 and 10,respectively.Moderate laryngomalacia and suboptimal vocal cord movements were diagnosed,and tracheotomy and percutaneous endoscopic gastrostomy were performed under general anesthesia in the same session at postoperative day 32.The patient was discharged on postoperative day 85 after a challenging postoperative period with additional airway and nutritional problems.CONCLUSION This is the first report of the perioperative anesthetic and clinical management of a CdLS patient undergoing open-heart surgery.

Goal-directed fluid therapy in gastrointestinal cancer surgery:A prospective randomized study

Objective:To investigate the effects of perioperative goal-directed fluid therapy(GDFT)on intraoperative fluid balance,postoperative morbidity,and mortality.Methods:This is a prospective randomized study,and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included.Patients were randomized into 2 groups that received liberal fluid therapy(the LFT group,n=45)and goal-directed fluid therapy(the GDFT group,n=45).Patients’Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity(CR-POSSUM)physiological score,Charlson Comorbidity Index(CCI),perioperative vasopressor and inotrope use,postoperative AKIN classification,postoperative intensive care unit(ICU)hospitalization,hospital stay,and 30-day mortality were recorded.Results:The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group(P<0.05).CR-POSSUM physiological score and CCI were significantly higher in the GDFT group(P<0.05).Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group(P<0.05),postoperative acute kidney injury development was not affected.Postoperative mortality was determined to be similar in both groups(P>0.05).Conclusion:Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery,and it can prevent perioperative fluid overload,and the postoperative results are comparable in the two groups.

Oxidative stress and its complications in human health

Under normal physiological conditions, a homeostatic balance exists between the formation of oxgyen radicals (ROS) and their removal by endogenous scavenging antioxidants. An imbalance between oxidants and antioxidants that is in favor of the oxidants potentially leading to damage is termed “oxidative stress”. Mitochondria are a major producer of ROS, which mainly consists of superoxide anion, hydrogen peroxide, and hydroxyl radical. Especially, during systemic inflammatory response syndrome, sepsis, septic shock, there is an overproduction of ROS while the natural antioxidant mechanisms are weakened, mainly because of endothelial cell damage. General anesthesia can impair the immunological defense mechanisms while inducing an inflammatory reaction in alveolar macrophages. In chronic diseases and high mortality situations like sepsis, oxidative/antioxidative equilibrium shifts to the direction of oxidative stress. When elderly patients with chronic diseases and patients with sepsis undergo surgical operations, anesthesia and anesthetic agents used increases the oxidative stress in addition to the surgical trauma. Thence many studies are ongoing on the antioxidant drugs and enzymes. We must never forget to take the oxidative stress of our patients into account while planning their treatments.