Effect of sodium-glucose co-transporter-2 inhibitors on coronary blood flow in patients with type 2 diabetes mellitus.

OBJECTIVE: Type 2 diabetes mellitus (T2DM) is known to be associated with endothelial dysfunction (ED). Reducing ED can attenuate the occurrence of cardiovascular diseases. One of the indicators of ED is decreased coronary blood flow (CBF). Sodium-glucose co-transporter 2 inhibitors (SGLT-2is) are known to directly improve ED in both euglycemic and hyperglycemic conditions and have been shown to decrease the incidence of major cardiovascular events. We aimed to investigate whether SGLT-2is improves CBF in patients with T2DM, who have angiographically normal or nearly normal coronary arteries. PATIENTS AND METHODS: In this single-center retrospective study, all patients who underwent coronary angiography between January 2017 and September 2022 were screened. We designed the study by dividing the patients into two groups - those who used conventional antidiabetic medications (CAM) together with SGLT-2is (patients using an SGLT-2 inhibitor for at least 3 months) and those who used only conventional antidiabetic medications. Of the 18,205 patients who underwent coronary angiography, 5,040 patients had T2DM. After exclusion, 288 patients were divided into two groups - those who used CAM together with SGLT-2is and those who used only CAM. CBF was assessed by thrombolysis in myocardial infarction (TIMI) frame counting. RESULTS: Two hundred eighty-eight patients who had T2DM and met the inclusion criteria were included in our study. The patients were divided into two groups - those who used CAM together with SGLT-2is (n = 75) and those who used only CAM (n = 213). The median age in the group that used CAM together with SGLT-2is was 55 (51-64), where 52 (69.3%) patients were female. The mean TIMI frame count (TFC) was 23.5 in the group using CAM + SGLT-2is and 27.5 in the group using only CAM. In the multivariable linear regression analysis, the mean TFC was significantly lower in the group using CAM together with SGLT-2is compared to the group using only CAM [ß-coefficient = -12.766, 95% Cl: -5.304; -3.887, p < 0.001]. Moreover, there was a statistically significant correlation between an increase in BMI and hemoglobin with an increase in the mean TFC [ß-coefficient = 3.018, 95% Cl 0.037-0.175, p = 0.003 and ß-coefficient = 2.316, 95% Cl 0.033-0.405, p = 0.021, respectively]. CONCLUSIONS: We have demonstrated that the use of SGLT-2is improves coronary artery blood flow in patients with T2DM who have normal or nearly normal coronary angiography.

Evaluation of the effect of bun/albumin ratio on in-hospital mortality in hypertensive COVID-19 patients.

OBJECTIVE: The impact of COVID-19 infection still continues all over the world and is an important cause of mortality. The mortality rate due to infection varies between 1-5%. The mortality rate is higher in those with cardiovascular risk factors, especially in cases with hypertension. Some studies have shown that blood urea nitrogen (BUN) and albumin levels are associated with worse prognosis in patients with COVID-19. In our study, we aimed to investigate whether the BUN/albumin (BAR) ratio has an effect on in-hospital mortality in hypertensive COVID-19 patients. PATIENTS AND METHODS: A total of 800 hypertensive COVID-19 patients, (618 of whom were alive and 182 died) were included in our study. Patients with a history of heart failure, malignancy, acute coronary syndrome, and myocarditis were excluded. RESULTS: The median age of the study population was 69 (60-77 IQR) years, and 305 (38%) of these patients were men. There was no statistically significant difference between the patients who died during follow-up and cases that remained alive in terms of comorbidities except chronic obstructive pulmonary disease (COPD) which was significantly lower in surviving group (p=0.014). Multivariable logistic regression analysis revealed that age [OR: 1.04, CI (1.01-1.06); p=0.002], male gender [OR: 1.85, CI (1.13-3.02); p=0.010], lymphocyte count [OR: 0.63, CI (0.40-0.98); p=0.038], SaO2 [OR: 0.82, CI (0.79-0.85); p<0.001] and BAR level [OR: 1.09, CI (1.04-1.16); p=0.001] were independent predictors of in-hospital mortality. ROC analysis yielded that BAR is a better predictor of in-hospital mortality compared to albumin and BUN alone. CONCLUSIONS: BUN, albumin, and BAR levels were found to be reliable predictors of in-hospital mortality in COVID-19 patients, and BAR was also found to be a more reliable predictor than BUN and albumin levels. Hypertension is one of the major risk factors for morbidity and mortality in COVID-19 and, BAR presents additional prognostic data in hypertensive COVID-19 patients that may direct physicians for treatment intensification.

Accuracy of two different voxel sizes for presurgical evaluation of mandibular osteotomy.

The aim of this study was to compare the accuracy of two different voxel resolutions for the preoperative assessment of mandibular osteotomies. The study was conducted on 37 dry adult human mandibles. To obtain measurement standardization, heated gutta-percha cones were placed on the dry mandibles to mark 20 anatomical points. These cones were used for all measurement groups. Cone beam computerized tomography (CBCT) scans of the mandibles were made using 0.200mm3 and 0.400mm3 voxel sizes (Planmeca Promex-3D Helsinki, Finland). The results obtained from these two groups were compared with physical measurements obtained using a digital calliper, in order to analyze their predictive value. In the study, one voxel size did not have supremacy over the other in terms of accuracy. For mandibular osteotomies, 0.400mm3 voxel size can be preferred because of lower radiation dose.

Re-defining the anatomical structures for blocking the nerves in adductor canal and sciatic nerve through the same injection site: an anatomical study.

PURPOSE: The aim of this study is to re-define the anatomical structures which are important for blocking the sciatic nerve and the nerves within the adductor canal which innervate the knee joint through the same injection site. We also aimed to investigate the spread of the anesthetic toward the areas in which the mentioned nerves lie on cadavers. METHODS: This study was performed on 16 lower extremities of formaldehyde-embalmed eight adult cadavers. The anatomy of adductor canal, courses of the nerves within the canal and the relationships of the saphenous, medial femoral cutaneous, medial retinacular, posterior branch of the obturator and sciatic nerves with each other and with the fascial compartments were investigated. Transverse sections that crossed the superior border of vastoadductor membrane were taken to reach the sciatic nerve in the shortest way. Colored latex was injected to demonstrate the anesthetic blockage of the targeted nerves. The structures along the needle's way were investigated. RESULTS: The saphenous, medial femoral cutaneous and at its distal part posterior branch of the obturator nerve were colored with latex within the adductor canal. The nerve to vastus medialis (in other words, the medial retinacular nerve) lay beneath the fascia of vastus medialis and did not enter the adductor canal. There was a fascial plane which did not allow the passage of colored latex toward the sciatic nerve. To traverse this fascial structure, it was found out to be necessary to insert the needle perpendicular to both the vertical and transverse axes of the thigh and then advance it along 2/3 of diameter of the thigh. Thus, the colored latex was observed to fill the compartment where the sciatic nerve lay within. CONCLUSIONS: Blocking the sciatic nerve and the nerves within the adductor canal which innervate the knee joint through the same injection site seems anatomically possible without injuring any neurovascular structures.

Effect of curing time on selected properties of soil stabilized with fly ash, marble dust and waste sand for road sub-base materials.

The properties of sub-base filling materials in highway construction are essential, as they can determine the performance of the road in service. Normally, the existing materials are removed and replaced with new materials that have adequate load-bearing capacity. Rising environmental concern and new environmental legislations have made construction professionals consider other methods. These methods include stabilizing the existing materials with other additives to improve their performance. Additives can be waste materials generated by different industries. In this work, the existing excavated soil is stabilized with waste materials. The wastes consisted of fly ash, marble dust and waste sand. The percentage addition of waste materials was 5%, 10%, 15% and 20% (by mass) of the existing soil. The soil/waste specimens were cured for 1, 7, 28, 56, 90 and 112 days before testing. Testing included the dry unit weight and unconfined compressive strength ( qu) as well as X-ray diffraction analysis and scanning electron microscopy observation. Also, the California Bearing Ratio values were obtained and are reported in this investigation. The results showed that the qu values increased with the increase in waste materials content. Also, there is tendency for the dry unit weight to increase with the increase in waste materials.

Ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in chronic pelvic pain.

Chronic pelvic pain is a condition that can be caused by pudendal neuralgia, interstitial cystitis, piriformis syndrome and neuropathy of the ilioinguinal, iliohypogastric and genitofemoral nerves. Based on three case reports this article discusses the clinical effectiveness of pulsed high-frequency radiofrequency (PRF) treatment applied to the pudendal nerve under ultrasound guidance in medicinally treated patients with chronic pelvic pain.

Arterial vascularization patterns of the splenium: An anatomical study.

The aim of this study was to provide detailed information about the arterial vascularization of the splenium of the corpus callosum (CC). The splenium is unique in that it is part of the largest commissural tract in the brain and a region in which pathologies are seen frequently. An exact description of the arterial vascularization of this part of the CC remains under debate. Thirty adult human brains (60 hemispheres) were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. Then, the brains were fixed in formaldehyde, and dissections were performed using a surgical microscope. The diameter of the arterial branches supplying the splenium of the CC at their origin was investigated, and the vascularization patterns of these branches were observed. Vascular supply to the splenium was provided by the anterior pericallosal artery (40%) from the anterior circulation and by the posterior pericallosal artery (88%) and posterior accessory pericallosal artery (50%) from the posterior circulation. The vascularization pattern of the splenium differs in each hemisphere and is usually supplied by multiple branches. The arterial vascularization of the splenium of the CC was studied comprehensively considering the ongoing debate and the inadequacy of the studies on this issue currently available in the literature. This anatomical knowledge is essential during the treatment of pathologies in this region and especially for splenial arteriovenous malformations.

Isotretinoin has no negative effect on attention, executive function and mood.

BACKGROUND: According to some animal data, impairments in learning and memory are seen with isotretinoin. Isotretinoin has been shown to affect human brain metabolism, but the data on human neural functions is lacking. OBJECTIVES: To evaluate whether isotretinoin treatment affects cognitive functions, causes depression and anxiety or alters anger level and anger expression. METHODS: Neuropsychological tests of attention and executive functions, behavioural tests measuring anger and depression and measures assessing acne severity were applied to 63 severe and/or resistant acne patients from four medical centres including one primary care institute and three university hospitals at the beginning, at the end of first month, third month and at end of treatment with isotretinoin. RESULTS: From a total of 63 patients, 15 missed the final visit and 48 were evaluated. Overall, 11 (six women, five men) and five (all women) patients reported anger and depression, respectively, during treatment. Eleven of these 16 patients improved spontaneously. No detrimental effects of isotretinoin treatment on either executive functions or mood were found. Several executive functions and control of anger trait were found to be improved. Clearing of acne was obtained in 94.6% of patients. LIMITATIONS: Improvement of several measures may be related to learning effect of repeated testing. Investigating brain functions is a complex process and various methods can be used. CONCLUSION: The test battery used in this study, which is commonly used to evaluate mental status both in adults and children, did not show any negative effect of isotretinoin on executive functional parameters in acne patients.

A case of connected superior and middle trunks of the brachial plexus or with abnormal upper trunk.

During treatment of tumors of nerve sheaths, such as schwannomas and neurofibromas, neurosurgeons should be aware of variations and aberrant formations of brachial plexus. Variations of the branches of brachial plexus are common, but its variations in the level of the roots and trunks are rare. Variations regarding lower trunk were founded more frequent in previous studies. An unusual variant of the brachial plexus was found unilaterally during routine dissection of a 75-year-old male cadaver. It was observed that middle trunk was connected to superior trunk. Deep cervical artery originating from subclavian artery passed between C6 and C7 roots. Similar variations in the brachial plexus were not observed on the contralateral side. In available literature, only two similar bilateral cases were reported. The details of this variation and its clinical significance were discussed. Knowledge about these rare variations in the trunks is very useful in surgical practice and anesthesia.

Torque-fitting and resonance frequency analyses of implants in conventional sockets versus controlled bone defects in vitro.

The primary stability of implants should be high on insertion into fresh extraction sockets. Torque-fitting and resonance frequency analyses (RFA) are used to assess primary implant anchorage and stability. The torque-fitting and RFA of implants placed in conventional surgical sockets and sockets with controlled coronal bone defects was compared. The possible relation between torque-fitting and RFA was explored. Ø 3.3 mm x 12 mm implants were placed in 16 sockets finalized with Ø 2.8mm surgical pilot drills in the right iliac crests of two fresh cadavers (control). In the test group, implants were placed into sockets prepared by Ø 2.8mm drill followed by Ø 4.2mm twist drills to a depth of 6mm to create circumferential controlled coronal bone defects (50% bone loss). Primary implant stability was assessed using insertion torque values (ITV) followed by RFA. Mean ITV and RFA measurements for test groups (7.83+/-0.91 N cm and 40.88+/-3.57) were significantly lower than controls (14.80+/-1 N cm and 66.31+/-0.9) (P<0.05). Reductions of ITV and RFA measurements in relation to bone defect were 47% and 38%. The existence of controlled bone defects eliminating contact coronally leads to decrease in torque-fitting and primary stability of implants. No relationship was observed between torque-fitting and RFA.

Anatomy of the reflected ligament of the inguinal region.

BACKGROUND: There is a paucity in the literature regarding the reflected ligament. Therefore, the present study was performed in order to further elucidate this anatomy. MATERIAL AND METHODS: Eighteen formalin-fixed adult cadavers (35 sides) underwent dissection of the medial inguinal region. The reflected ligament was observed for and when identified, its dimensions were measured. RESULTS: 83% of sides were found to have a reflected ligament. These were identified in 16 male and 13 female bodies. The size and shape for the reflected ligaments were variable but overall, triangular in nature. In general, the reflected ligament was found to extend from the lacunar and medial inguinal ligaments and extended obliquely toward the midline at an approximate 45 degrees angle to insert near the linea alba. Two ligaments (6.9 %) were identified that interdigitated with the contralateral reflected ligament. The medial and lateral lengths of the ligament had a mean measurement of 2.28 and 2.58 cm. The base of the reflected ligament had a mean of 2.52 cm and the height of this ligament was found to have a mean of 2.56 cm. The mean area of the reflected ligament was calculated as 2.93 cm(2). There was no statistically significant difference between right or left sides or between genders. CONCLUSIONS: The reflected ligament was identified in the majority of our specimens and this structure usually contributed to the formation of the posteromedial wall of the external inguinal ring. Therefore, this fact should be included in future descriptions of this ligament.

The costoclavicular ligament revisited: a functional and anatomical study.

INTRODUCTION: The sternoclavicular joint is of clinical importance. However, there is scant information in the literature regarding one ligament of this area, the costoclavicular ligament (CCL). MATERIAL AND METHODS: In order to further elucidate this structure, 10 adult formalin-fixed cadavers (17 sides) underwent dissection of the CCL. Once the CCL was identified, measurements were made of its dimensions and observations made of its anatomy. Next, ranges of motion were performed of the upper extremity and the CCL observed for tension or laxity. RESULTS: Of the 17 sternoclavicular regions examined 16 (94%) were found to possess a CCL. The average medial and lateral lengths, width and thickness were 1, 2, 1.2, 0.340 cm, respectively. The width of the CCL was statistically smaller in women that in men. The majority of ligaments were single structures traveling from the inferior surface of the medial clavicle just lateral and sometimes-fused (12.5%) to the lateral edge of the sternoclavicular joint. These fibers then terminated on the medial end of the first rib and first costal cartilage (75%) or exclusively onto the first costal cartilage (25%). Most ligaments were single and not composed of two parts. Arm abduction resulted in tautness of the ligament and increased as the degree of abduction increased. Internal rotation of the arm translated into medial shift of the clavicle, raising the clavicle away from the first rib creating tension on the CCL. Moderate degrees of external rotation were required before the CCL became taut and even began to pull the first rib laterally. Small amounts of protraction and retraction of the scapula both put the CCL under tension. CONCLUSIONS: The CCL is a constant structure found just lateral to the sternoclavicular joint. This ligament was a single band in the majority of our specimens and limited most ranges of motion of the proximal upper limb thus stabilizing the sternoclavicular region.

The long thoracic nerve: Its origin, branches, and relationship to the middle scalene muscle.

Anatomical knowledge regarding the long thoracic nerve (LTN) is important during surgical procedures considering that dysfunction of this nerve results in clinical problems. The purpose of this study was to explore the anatomy of the LTN, its origin, configuration, branching pattern, and relationship to the middle scalene muscle (MSM). The course of the LTN was investigated in 12 embalmed cadavers (21 sides). We defined four different types for this nerve according to the origins of its roots. The most common formation of the LTN was the contribution of three branches that originated from the fifth, sixth, and seventh cervical ventral roots. C5 and C6 components or upper portion of the LTN roots lay primarily between the middle and posterior scalene muscles, sometimes passed through the MSM, and less frequently coursed over the MSM. C7 contributions to the LTN were always located anterior to the MSM. Contributions from C8 were also found over the MSM. The median number of branches arising directly from the cervical roots and branches arising from the main trunk of the nerve were 3 and 7, respectively. Along its course, the median number of branches to the serratus anterior was 10.

Endoscopic anatomy of sphenoid sinus for pituitary surgery.

Endoscopic endonasal transsphenoidal approach to the sellar region yields an alternative to classical microsurgical approaches. Endoscopes provide images that differ from microscopic view. This study aimed to highlight surgical landmarks and their anatomical relationships for pituitary surgery through endoscopic perspective. Ten sides of five adult cadaveric heads with red-colored latex injected arteries were evaluated. Endoscopic dissections were performed and measurements were done in the sphenoid sinuses before and after the removal of bony structures in all the aspects. Endoscopic vision of the sellar region enabled a wide panoramic perspective and detailed inspection. The measurements, in general, indicated the variations in the bony structures and soft tissues. The width of the pituitary, which is the distance between the medial margins of the carotid prominences, was measured as 21 +/- 2.5 mm and the distance between the medial margin of the carotid prominences at the lower margin of the pituitary was 18 +/- 3.1 mm. After the bony structures were removed, further measurements were done. The width of the pituitary, which is the distance between the medial margins of the anterior curvature of the ICA, was measured as 23.2 +/- 3 mm, while the distance between the posterior curvature of the ICA was 19.7 +/- 4.9 mm. Endoscopic view provided superior detailed visualization of the close relationships between pituitary gland, internal carotid arteries, and optic nerves. This facilitated exact evaluation for variations, which could result in more effective and safe surgery. However, these variations again emphasize the necessity of preoperative radiological evaluation in each case.

Callosal branches of the anterior cerebral artery: an anatomical report.

Although the morphology of the corpus callosum is well defined, the arterial supply of this structure has not been comprehensively studied. To elucidate this further, 40 cerebral hemispheres from 30 adult cadaveric brains were obtained. The anterior cerebral arteries were cannulated and injected with red latex. The following were observed and documented: (1) the number, diameter, and course of the arteries supplying the corpus callosum; (2) the territories vascularized by these arteries; (3) any variations of the callosal arteries. Short callosal arteries were present in 58 hemispheres (96.6%) and supplied the superficial surface of the corpus callosum along its midline and were a primary arterial source to this structure. Long callosal arteries were found in 28 hemispheres (46.6%) and contributed to the pial plexus. The cingulocallosal arteries were present in all hemispheres and supplied the corpus callosum, cingulate gyrus, and also contributed to the pericallosal pial plexus. The recurrent cingulocallosal arteries were present in 17 hemispheres (28.3%) and also contributed to the pericallosal pial plexus. The median callosal artery, an anatomical variation, was present in 10 brains (33.3%). This vessel supplied the corpus callosum and the cingulate gyrus. The aim of the present study was to provide a detailed description of the arteries supplying the corpus callosum for those who encounter these vessels radiologically or surgically.

The location of the obturator nerve: a three-dimensional description of the obturator canal.

Satisfactory analgesia cannot be achieved in every obturator nerve block. To attempt to improve the success rate of obturator nerve block, this study describes the detailed anatomy of the obturator region and canal. Eleven (5 female and 6 male) cadavers, totally 22 sides were dissected. Anatomical positions of the structures entering and leaving the canal were defined. The position of the obturator nerve and its branches and their relation with the obturator artery, vein, and with the internal iliac and femoral veins were investigated. A mould of the canal and a model were created. Detailed measurements were performed on the cadavers and models. The obturator canal was in the shape of a funnel compressed from superior to inferior, with anterior and posterior openings. At the entrance of the canal, the nerve lay superiorly; the artery was in the middle, and the vein lay inferiorly. The obturator nerve ran close to the lateral wall of the obturator canal. The distance of lateral wall of obturator canal to the median plane was 41.4 +/- 1.1 mm. After leaving the canal, the nerve lay laterally while the anterior branch of the artery was medial. A venous plexus lay between the two structures. The presence of the branches of the obturator artery and vein alongside the obturator nerve may increase the risk of injury to these structures during anaesthetic procedures. The anterior division of the obturator nerve has a close relationship with these vessels. To provide complete analgesia, the obturator nerve should be blocked in the obturator canal or at its external orifice.

Detailed anatomy of accessory obturator nerve blockade.

BACKGROUND: The accessory obturator nerve (AON) often innervates the hip joint and adductor longus. The AON is present in 10-30% of patients, and thus it is clinically important that it is also considered during obturator nerve (ON) blockade. METHODS: The study was performed on 12 cadavers (24 body-sides) and the AON beginning from the lumbar plexus was observed. The needle was classically penetrated into the ON to gain access to the AON and upon definition of detailed AON anatomy, morphometric measurements were conducted. In addition, novel maneuvers used in the study were described. RESULTS: Throughout the dissections, the AON was detected on three sides (12.5%) and the mean AON- pubic tubercle distance was measured as 4.0 cm. The needle was withdrawn and positioned medially and almost parallel to the skin. It was then advanced through the superior pubic ramus to reach the AON. CONCLUSION: Owing to its anatomical structure, the AON can be easily accessed during classical ON blockade using the maneuvers described here. Further clinical studies are needed to investigate if supplementing ON blockade with AON blockade might improve the clinical efficiency and quality of the blockade.

Infragluteal sulcus: a combined histologic and anatomic reappraisal.

The infragluteal fold is one of the major concerns in reshaping of the gluteal region. This study reevaluated the fold both histologically and anatomically. Five fixed cadavers were used. The infragluteal fold on the right side was explored by dissection, whereas the infragluteal fold of the contralateral side was removed en bloc. Tissue samples (6 cm long x 2 mm thick) were taken at three points from each fold bloc: the most medial point, the middle point, and the most lateral end of the sulcus. Anatomic dissections and histologic examinations showed that the infragluteal fold consists of strong fibrous bands extending from the dermis of the medial one-third of the fold to the ramus of the ischium and sacrum, forming the letter J. The infragluteal fold, which attaches to both the ischium and the sacrum in a continuous fashion, is an anatomic structure in its medial part and only a crease laterally.

Painless burn injury caused by post-traumatic syringomyelia.

BACKGROUND: Syringomyelia, which is generally related to congenital malformations and tumors, may lead to paresthesia and dysfunctions in thermo-algesic perception. Post-traumatic syringomyelia (PTS) is a rare type of this disease characterised by the development of a cystic formation containing cerebrospinal fluid (CSF), which develops inside the spinal cord after spinal trauma. AIM: The description of a case diagnosed as painless burn injury caused by PTS. METHOD: One case report. CONCLUSION: Although there are a number of reports regarding the formation of neuropathic ulcers related to syringomyelia, painless burn injury descriptions are very rare. Despite available limited data related to this subject, it is important to warn patients about traumas-especially burns-after a diagnosis of PTS.