Evaluation of Blood Pressure Status and Mortality in Turkey: Findings from Chronic Diseases and Risk Factors Cohort Study.

Background and objectives: An important Non-Communicable Disease risk factor, hypertension (HT), is highly prevalent and controlled HT rates are not sufficient which increases the risk of developing premature deaths. The purpose of the study is to evaluate differences in all-cause and cardiovascular-related mortality according to HT status by using national data from Chronic Diseases and Risk Factors Survey in Turkey (2011-2017). Materials and Methods: Cox regression models were used to estimate hazard ratios (HR) for predicting the all-cause and cardiovascular system-related mortalities. Median follow-up period was 6.2 years. Results: Among individuals with HT, 41.8% was untreated, 30.1% received treatment and had controlled blood pressure, and 28.1% were under treatment but had uncontrolled BP levels. The hazard for mortality among treated & uncontrolled hypertensive participants was significantly higher for all-cause (HR = 1.32, 95% CI = 1.06-1.65), cardiovascular (HR = 2.11, 95% CI = 1.46-3.06), heart disease (HR = 2.24, 95% CI = 1.46-3.43), and Coronary Heart Disease mortality (HR = 2.66, 95% CI = 1.56-4.53) compared to normotensive participants. Conclusions: Individuals with HT who were treated but do not have controlled blood pressure in Turkey had a significantly increased risk of Cardiovascular Disease and all-cause mortality. Along with studies investigating the causes of uncontrolled blood pressure despite initiation of treatment, support should be provided to patients in cases of non-adherence to antihypertensive medication or life change recommendations.

Comparison of tidal volume and deep breath preoxygenation techniquesundergoing coronary artery bypass graft surgery: effects of hemodynamicresponse and arterial oxygenation

Background/aim: Different techniques exist for the preoxygenation of patients that will be operated on under general anesthesia. Preoxygenation with the deep breath (DB) method may affect cardiovascular stability, which is crucial for coronary artery bypass graft (CABG) patients. In this study, we aimed to compare the effects of the 3 min TVB preoxygenation technique and 1 min 8DBs technique on hemodynamic response and arterial oxygenation in patients with normal ejection fraction that were scheduled for elective CABG surgery. Materials and methods: Forty patients classified as ASA II?III and scheduled for elective CABG surgery were randomly assigned to TVB/3 min or 8DBs/1 min for preoxygenation. Cardiovascular variables, i.e. heart rate, mean arterial pressure, central venous pressure, cardiac index, systemic vascular resistance index, and stroke volume index, and arterial blood gas samples were analyzed before and after preoxygenation and at the end of the apneic period before intubation. Results: The preoxygenation methods affected the hemodynamic response similarly. PaO2 increased significantly with 8DBs compared to the TVB at the end of preoxygenation but was similar between the groups at the end of the apneic period (respectively, P: 0.03; P: 0.15). PaCO2 changes were similar between the groups. Conclusion: In patients with normal ejection fraction scheduled for CABG, 8DBs can be an alternative to TVB preoxygenation. Our results should be compared with those of other studies.

Importance of Clinical Decision Making by Experienced Pediatric Surgeons When Children Are Suspected of Having Acute Appendicitis: The Reality in a High-Volume Pediatric Emergency Department.

OBJECTIVE: The aim of the present study was to compare the pediatric appendicitis score (PAS), the Alvarado score (AS), white blood cell count (WBC), absolute neutrophil count (ANC), C-reactive protein (CRP) level, procalcitonin level, and ultrasound (US) data, with the appendectomy decisions of pediatric surgeons diagnosing acute appendicitis (AA) in a real-life setting; this was a top-level, high-volume pediatric emergency department (PED) in a developing country. METHODS: The study was conducted prospectively between January 2012 and June 2013 in the PED of the Tepecik Teaching and Research Hospital in Izmir, Turkey. The study was observational in nature; no attempt was made to influence indications for exploration or the timing thereof. Children aged 4 to 18 years presenting to the PED on suspicion of AA were included. The WBC, ANC, CRP level, and procalcitonin level were measured, and US was performed on all patients on admission. The PAS and AS were calculated. An operative decision was made by each pediatric surgeon who had the results of laboratory and radiological tests. The criterion standard for AA was histopathological assessment. RESULTS: Upon receiver operating curve (ROC) analysis, the areas under the ROCs (AUROCs) of the WBC, ANC, CRP level, procalcitonin level, US positivity, PAS, AS, and decisions of pediatric surgeons supported by laboratory and US data were 0.734, 0.741, 0.671, 0.675, 0.670, 0.831, 0.794, and 0.910, respectively. When US data were employed only in cases with PASs 4 to 7, the sensitivity increased but specificity decreased. The sensitivity and specificity of pediatric surgical decisions were 100% and 82.50%, respectively. The difference between the PAS AUROC and the pediatric surgeon decision-making AUROC was significant (P = 0.0393; 95% confidence interval, 0.0470-0.226). CONCLUSIONS: Good pediatric surgical decision making supported by laboratory and US data for those suspected of AA may be the most effective diagnostic tool in a high-volume PED in a developing country.

Meckel's diverticulum: Ten years' experience.

OBJECTIVE: To evaluate the demographics and characteristics of children with Meckel's diverticulum (MD). MATERIAL AND METHODS: In this retrospective study, we analyzed the medical records of all children who were treated for MD in the department of pediatric surgery of Tepecik Training and Research Hospital over a period of 10 years (1995-2004). Age, gender, clinical manifestations, diagnostic approaches, and histopathological reports were documented. RESULTS: In total, 57 children were diagnosed with MD. Of these, 40 children were treated surgically. Furthermore, 26 had acute abdomen, 15 had intestinal obstruction, 10 had rectal bleeding, and 6 had some other diagnosis. The mean age of the boys (n=43) was 4.77±3.82 years, whereas that of the girls (n=14) was 3.85±3.67 years. Histopathological examination revealed ectopic mucosa in 9 patients, omphalomesenteric duct remnants in 4 patients, diverticulitis in 24 patients, and ulcerations in 14 patients. CONCLUSION: The prevalence of MD was 1.6%. Boys were approximately 3 times more commonly affected than girls. In most cases, the initial diagnosis was acute abdomen and the presenting symptoms on admission were intestinal obstruction and rectal bleeding.

Postoperative apnea after inguinal hernia repair in formerly premature infants: impacts of gestational age, postconceptional age and comorbidities.

PURPOSE: It is common practice for premature infants undergoing elective inguinal hernia (IH) repair to be hospitalized for postoperative apnea monitoring. This study evaluated the risk of apnea after IH repair with regard to gestational age (GA) and postconceptional age (PCA) in formerly premature infants. METHODS: Formerly premature infants who had undergone elective IH repair between 01/2000 and 12/2012 were reviewed retrospectively in terms of GA, PCA, body weight, and comorbidities. All postoperative apneas were evaluated. RESULTS: A total of 428 formerly premature infant charts were reviewed. Eleven babies had postoperative apnea. Infants younger than 45 weeks PCA were found more prone to develop postoperative apnea after IH repair. In older infants (PCA between 46 and 60 weeks), comorbidities create predisposition to apnea postoperatively. These comorbidities are bronchopulmonary dysplasia, necrotizing enterocolitis and former apnea episodes. Anemia and lower birth weight are also risk factors. CONCLUSION: This study suggests that low GA and PCA, low birth weight, anemia, and complicated past medical history affect respiratory complication rates, particularly apnea in formerly premature infants undergoing elective IH repair. Severe apneas occurred earlier than mild ones. Overnight monitoring is mandatory in small infants with low GA and PCA. Otherwise healthy, older infants may be operated on outpatient basis.

Ureterocystoplasty in pediatric patients with unilateral nonfunctioning kidney.

OBJECTIVE: Bladder augmentation with uroepithelium lined material yields an absence of mucus production, with reduced possibility of urinary infection and lithiasis. The utilization of the ureter in augmentation cystoplasty results in a uroepithelium-lined neobladder with all of the appropriate histologic layers. The purpose of this study was to assess the efficacy and safety of ureterocystoplasty in children with a small bladder capacity and low bladder compliance. MATERIAL AND METHODS: Between January 1992 and August 2011, six females and eight males who were 3 to 13 years old (median age 6 years) and had a low-capacity, poorly compliant bladder underwent augmentation cystoplasty using dilated ureters. Unilateral non-functioning renal moiety draining into a massively dilated ureter was present in every patient. The etiology of hydroureteronephrosis was a neurogenic bladder secondary to meningomyelocele in five patients, a posterior urethral valve in four patients, an obstructive megaureter in three patients and ectopic obstructive ureterocele in two patients. RESULTS: Mean age was 6 years (3-13 y). Clinical improvement regarding the resolution of reflux, a better bladder capacity and improved compliance was achieved in every patient. The increase in bladder capacity ranged from 84 cc (30 to 200) to 235 cc (150 to 420), with a mean increase of 318% (210 to 500). Marked improvement in compliance was also observed (from 1.2 to 5.1 mL/cm H2O, mean 2.4, to 22 to 50 mL/cm H2O, mean 41). No uninhibited bladder contractions were detected during a urodynamic study at 12 months postoperatively. CONCLUSION: In patients with a low-capacity, poorly compliant bladder, augmentation cystoplasty using the ureter seems to be a viable alternative. Ureterocystoplasty results in a large-capacity, high-compliance bladder, without metabolic and infective complications, compared with other techniques of augmentation cystoplasty.

The relationship between clinical findings and esophageal injury severity in children with corrosive agent ingestion.

BACKGROUND: The aim of the study was to investigate the indicators of corrosive esophageal injury (EI) severity in children. METHODS: We retrospectively reviewed data from children who accidentally ingested corrosive substance and underwent endoscopic evaluation over a one-year period. A total of 134 consecutive children with corrosive agent ingestion who underwent diagnostic endoscopy (74 boys, 60 girls) were included in this study. Patients were divided into two groups as low-grade and high-grade EI. Statistical differences and predictive values of common signs and symptoms and white blood cell (WBC) count of patients with low- and high-grade EI were analyzed. RESULTS: The majority of patients (70%) were asymptomatic at the initial examination. We found that drooling saliva and oral lesions were significantly more frequent in high-grade injury (p<0.05). Mean WBC count in the high-grade EI group was significantly higher than in the low-grade EI group (p=0.000). Sensitivity, specificity and predictive values of clinical findings in children were analyzed; none of them was shown to be valuable for estimating EI severity. WBC count was sensitive, but it is not a good predictor. CONCLUSION: Our study demonstrated the relationship between clinical findings and corrosive EI severity in children with accidental corrosive ingestion, but direct visualization of the esophagus is required for definitive diagnosis.

One day hospitalization after open, double-J stented pyeloplasty.

BACKGROUND: This study was undertaken to assess the effect of antegrade placement of internal double-J catheters for patients who underwent open pyeloplasty for ureteropelvic junction (UPJ) obstruction. METHODS: Medical records of unilateral dismembered pyeloplasties of 71 patients with UPJ obstruction treated between 1998 and 2008 were reviewed retrospectively. In all patients, a double-J catheter was placed in an antegrade fashion during the operation. The patients were reviewed in terms of age, sex, postoperative complications and length of hospital stay. RESULTS: All children but one using double-J catheter were discharged within 24 hours after the operation. Neither urinary leak nor re-obstruction occurred in the operated kidneys during a follow-up. CONCLUSION: Transanastomotic stenting with double-J catheter is recommended as the reasonable mode of drainage in open pyeloplasty in pediatric patients.

[Spontaneous bile duct perforation: a rare cause of acute abdominal pain during childhood]. / Spontan koledok perforasyonu: Cocukluk çaginda nadir bir akut karin nedeni.

BACKGROUND: Spontaneous perforation of the bile duct (SPBD) is a rare cause of acute abdominal pain during childhood. Pancreatico-biliary malfunction has been postulated to contribute to its etiology. Factors related to diagnosis and treatment and difference from the other common causes of acute abdominal pain are emphasized. METHODS: Five patients (3 boys, 2 girls, mean age 4.6) were admitted with peritonitis and operated with initial diagnosis of perforated appendicitis. During laparotomy, SPBD was detected. Presentation, laboratory findings and operative technique of the patients were evaluated retrospectively. RESULTS: Common complaints were abdominal pain and bilious vomiting. Abdominal distention was present in all patients. Leukocytosis and mild hyperbilirubinemia were detected in 5, elevated serum transaminase levels in 4, hyperglycemia in 1 and constipation in 1 patient(s). Abdominal ultrasonography showed a large amount of free fluid. During laparotomy, sterile bile peritonitis was detected initially. After exploration, SPBD was seen. T-tube drainage of the bile duct was carried out. Patients were discharged after removal of the T-tubes. Pancreatico-biliary malfunction was detected in 4 of 5 patients. CONCLUSION: In patients with generalized peritonitis, elevated transaminase levels and hyperbilirubinemia, SPBD must be considered. Even though the T-tube drainage is the treatment of choice, Roux-en-Y hepatico-portoenterostomy may be mandatory in certain patients.

Management of a rare cause of neonatal airway obstruction: cervical teratoma.

Cervical teratomas are rare tumors during the prenatal period. Cervical teratomas account for 1.5-5.5% of all pediatric teratomas. Both mortality and morbidity are significantly high because of airway obstruction due to a mass effect of the tumor although good results are achieved with total excision of the mass. Antenatal diagnosis by routine ultrasound (US) screening helps in preparing a team to provide airway support and surgery. We present two cases of cervical teratomas with total excision and cure and a postmortem study from our pathology laboratory. The third case, the female infant who died soon after birth, demonstrates the paramount importance of antenatal diagnosis.

Safe removal of upper esophageal coins by using Magill forceps: two centers' experience.

Coin ingestion with subsequent esophageal coin impaction is common in children. Considerable debate surrounds the choice of technique for the removal of esophageal coins. This study demonstrates a minimally invasive technique for upper esophageal coin extraction. A retrospective review was conducted of 165 children who had upper esophageal coins extracted by using a Magill forceps. One hundred fifty-six coins (96.4%) were successfully removed without any complications. The average time taken to remove the coin was 33 seconds. Use of the Magill forceps technique minimizes instrumentation of the esophagus and is an easy, safe technique for removing coins from the upper end of the esophagus.

Treatment of gastroesophageal reflux with a gastric tube cardioplasty.

PURPOSE: Surgical control of gastroesophageal reflux (GER) is a challenging problem especially in neurologically impaired children and in acquired GER patients after caustic insult to the esophagus because of high failure rates of the classical antireflux procedures. A surgical technique has been designed to overcome this high relapse incidence. METHODS: During the past 75 months, 39 children between 4 months and 14 years of age underwent a gastric tube cardioplasty fashioned from the lesser curvature as the antireflux barrier. RESULTS: In all patients, the preoperative RI values of 72 to 10 (average, 32) fell to 0 to 5 (average, 2) after the described procedure, and, in the follow-up period of 2 to 75 months, the RI values did not deteriorate in any one of the cases. CONCLUSIONS: It is possible that a 6-cm antireflux barrier (HPZ) created from the lesser curvature of the stomach is enough to control GER at any age.

Experience of the Izmir Pediatric Oncology Group on Neuroblastoma: IPOG-NBL-92 Protocol.

This multicentric study aimed to bring neuroblastoma patients together under IPOG-NBL-92 protocol and evaluate the results within the period between 1992 and 2001 in Izmir. Sixty-seven neuroblastoma patients from 4 pediatric oncology centers in Izmir were included in the study. IPOG-NBL-92 protocol modified from German Pediatric Oncology (GPO)-NB-90 protocol was applied: Patients in stage 1 received only surgery, while surgery plus 4 chemotherapy courses (cisplatin, vincristine, ifosfamide) were given in stage 2 and surgery plus 6 chemotherapy courses (cisplatin, vincristine, ifosfamide, epirubicin, cyclophosphamide) were given in stages 3 and 4 patients. In patients who were kept in complete remission (CR), a maintenance therapy of one year was applied. Radiotherapy was given to the primary site following induction chemotherapy plus surgery in stages 3 and 4 patients with partial remission (PR). The stages of the patients were as follows: 5% in stage 1, 39% in stage 3, 49% in stage 4, and 7% in stage 4S. Primary tumor site was abdomen in 88% of cases. CR rates were as 100% in stage 1, 76% in stage 3, 35% in stage 4, and 75% in stage 4S. Relapse was observed in 32% of patients in a median of 19 months. The median follow-up time for survivors was 33 (17-102) months. Five-year OS rate was 31% and the EFS rate was 30% in all patients. Five-year overall and event-free survival rates were 63 and 30% in stage 3, but 6 and 5%, respectively, in stage 4 patients. Univariate analysis established that the age, stage, primary tumor site, and high LDH and NSE levels conferred a significant difference. The IPOG-NBL-92 protocol has proved to be satisfactory with tolerable toxicity and reasonable CR and survival rates. However, more effective treatments suitable to Turkey's social and economic conditions are urgently needed for children over 1 year of age with advanced neuroblastoma.

Foreign body aspiration: a four-years experience.

BACKGROUND: Foreign bodies (FB) in the airway require prompt removal in children. We reviewed our experience in patients with suspected airway FB. METHODS: A retrospective study was conducted in 189 consecutive children who admitted to the Department of Pediatric Surgery, SSK Tepecik Training Hospital between 1997-2001. Patients data on presentation, bronchoscopy findings and results were obtained. Of the 189 bronchoscopies, 127 (67.2%) showed FB which are commonly located in the right mainstem bronchus. Most of FB were nonradiopaque. Pips and hazelnuts were the most common FB. Mean hospital stay was 2.5 days. Many patients (151 out of 189; 79.9%) had transient stridor or fever that ceased within 24 hours after bronchoscopy. No mortality was observed rin relation with bronchoscopy. CONCLUSION: Chest radiographs of the children with FB in the airways are inconclusive. Children with a history of small particles in their mouths and subsequently showing wheezing, or choking episode should undergo prompt bronchoscopy. Complications related to bronchoscopy are uncommon.

Familial vesicoureteral reflux in asymptomatic siblings.

A prospective study was established to identify the incidence of vesicoureteral reflux in the asymptomatic siblings of patients with reflux in our region. Of 32 patients with reflux, 37 siblings were screened with urine analysis, urine culture and contrast voiding cystourethrograms, and six (16.2%) were found to have reflux. Renal scan revealed scarring in five. We concluded that siblings of children with vesicoureteral reflux are at high risk, and must be screened so that renal damage and associated morbidity secondary to reflux might be minimized.