Determining the Risk Factors for Anastomotic Stricture Development after Esophageal Atresia Repair: Results from the Turkish Esophageal Atresia Registry.

INTRODUCTION: Anastomotic stricture (AS) is the second most common complication after esophageal atresia (EA) repair. We aimed to evaluate the data in the Turkish Esophageal Atresia Registry to determine the risk factors for AS development after EA repair in a large national cohort of patients. METHODS: The data between 2015 and 2021 were evaluated. Patients were enrolled into two groups according to the occurrence of AS. Patients with AS (AS group) and without AS (non-AS group) were compared according to demographic and operative features, postoperative intubation status, and postoperative complications, such as anastomotic leaks, fistula recanalization, and the presence of gastroesophageal reflux (GER). A multivariable logistic regression analysis was performed to define the risk factors for the development of AS after EA repair. RESULTS: Among the 713 cases, 144 patients (20.19%) were enrolled into the AS group and 569 (79.81%) in the non-AS group. The multivariable logistic regression showed that, being a term baby (odds ratio [OR]: 1.706; p = 0.006), having a birth weight over 2,500 g (OR: 1.72; p = 0.006), presence of GER (OR: 5.267; p < 0.001), or having a recurrent tracheoesophageal fistula (TEF, OR: 4.363; p = 0.006) were the risk factors for the development of AS. CONCLUSIONS: The results of our national registry demonstrate that 20% of EA patients developed AS within their first year of life. In patients with early primary anastomosis, birth weight greater than 2,500 g and presence of GER were risk factors for developing AS. When patients with delayed anastomosis were included, in addition to the previous risk factors, being a term baby, and having recurrent TEF also became risk factors. LEVEL OF EVIDENCE: III.

Unusual neonatal case of superior mesenteric artery syndrome with Meckel's diverticulum and literature review.

Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction which is characterized by compression of the duodenum due to narrowing of the space between the superior mesenteric artery and aorta. Incomplete duodenal obstruction due to SMAS in neonates is rarely reported in the literature. In this case, it is a full-term 2-day-old male with the complaint of recurrent vomiting starting soon after birth. The patient was diagnosed with SMAS and duodenoduodenostomy was performed. Accompanying Meckel's diverticulum was excised.

El síndrome de la arteria mesentérica superior (SMAS) es una causa rara de obstrucción duodenal que se caracteriza por la compresión del duodeno debido al estrechamiento del espacio entre la arteria mesentérica superior y la aorta. La obstrucción duodenal incompleta por SMAS en recién nacidos rara vez se informa en la literatura. En este caso se trata de un varón de 2 días nacido a término que presenta vómitos recurrentes desde poco después del nacimiento. El paciente fue diagnosticado de SMAS y se le realizó duodenoduodenostomía. Se extirpó el divertículo de Meckel que lo acompañaba.

The effect of postoperative ventilation strategies on postoperative complications and outcomes in patients with esophageal atresia: Results from the Turkish Esophageal Atresia Registry.

OBJECTIVES: Postoperative ventilatory strategies in patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) may have an impact on early postoperative complications. Our national Esophageal Atresia Registry was evaluated to define a possible relationship between the type and duration of respiratory support on postoperative complications and outcome. STUDY DESIGN: Among the data registered by 31 centers between 2015 and 2021, patients with esophago-esophageal anastomosis (EEA)/tracheoesophageal fistula (TEF) were divided into two groups; invasive ventilatory support (IV) and noninvasive ventilatory support and/or oxygen support (NIV-OS). The demographic findings, gestational age, type of atresia, associated anomalies, and genetic malformations were evaluated. We compared the type of repair, gap length, chest tube insertion, follow-up times, tensioned anastomosis, postoperative complications, esophageal dilatations, respiratory problems requiring treatment after the operation, and mortality rates. RESULTS: Among 650 registered patients, 502 patients with EEA/TEF repair included the study. Four hundred and seventy of patients require IV and 32 of them had NIV-OS treatment. The IV group had lower mean birth weights and higher incidence of respiratory problems when compared to NIV-OS group. Also, NIV-OS group had significantly higher incidence of associated anomalies than IV groups. The rates of postoperative complications and mortality were not different between the IV and NIV-OS groups. CONCLUSION: We demonstrated that patients who required invasive ventilation had a higher incidence of low birth weight and respiratory morbidity. We found no relation between mode of postoperative ventilation and surgical complications. Randomized controlled trials and clinical guidelines are needed to define the best type of ventilation strategy in children with EA/TEF.

Ocular changes in nephrotic syndrome patients with preserved renal functions.

BACKGROUND: Optical coherence tomography (OCT) measurements of central choroidal thickness (CCT) and retinal thickness have been proposed as inflammatory indicators for a variety of systemic disorders, particularly those with a vascular component. The relationship between nephrotic syndrome (NS) and visual impairment is not clear. The aim of this study was to evaluate the ocular changes in primary NS patients with preserved renal functions. METHODS: A total of 60 participants (30 NS patients, 30 healthy control subjects) was recruited in this cross-sectional and comparative study. Retinal and choroidal examinations were performed via the spectral domain OCT. Enhanced depth imaging (EDI) mode of the OCT was used for choroidal analysis. RESULTS: Although not statistically significant, CCT was found to be higher in the NS group compared to the control group (p = 0.07). Central foveal thickness (CFT) and retinal arteriolar caliber (RAC) values were statistically significantly lower in the patients with nephrotic syndrome, whereas retinal venular caliber (RVC) and choroidal vascularity index (CVI) values were similar in both groups. RAC and RVC were not statistically significantly correlated with CCT or CFT in both groups (p > 0.05). CONCLUSION: The results of the current study showed a significant difference between the NS group and the control group in terms of some ocular changes (i.e., CFT and RAC). As a result, CCT, CFT and RAC measurements with OCT may be used as a marker of inflammation in NS patients.

The ecological footprint facing asymmetric natural resources challenges: evidence from the USA.

One of the most critical problems of today is the environmental policies with the focus on economy. Despite the many efforts of global organizations, environmental pollution is the subject of human beings. For this, the most polluting countries attract the attention of researchers. Many studies produce economy-centered environmental policies for the USA. However, the asymmetric effect of natural resources on environmental pollution has been neglected in the literature. In this paper, the effects of economic growth, renewable energy, biocapacity, and natural resources on the ecological footprint are addressed within the framework of the Environmental Kuznets Curve hypothesis over the period 1980-2017. Empirical findings confirm that economic growth and biocapacity increase environmental degradation, while renewable energy consumption helps reduce environmental damage. More specifically, when the results are analyzed in terms of natural resources, positive shocks in natural resources contribute to reducing environmental damage, while negative shocks in it negatively affect the environmental quality. The paper presents important policy implications for economy-centered environmental issues.

Comparing the fecal continence scores of patients with anorectal malformation with anorectal manometric findings.

BACKGROUND: Patients undergoing surgery for anorectal malformation (ARM) may have defecation-related problems throughout their lives, even if they are perfect treated surgically. Assessment methods are needed to standardize the clinical outcomes of patients with ARM. The aim of this study was to compare the scoring systems (SS) with the anorectal manometry (AM) findings. METHODS: The data of patients operated on for ARM were examined. Holschneider's, Rintala's, Krickenbeck's and Peña's questionnaires were executed to the patients and AM was performed. RESULTS: Our study was completed with 23 patients. There was a statistically significant relationship between the anal resting pressure and Holschneider's questionnaire (HQ). There was a statistically significant relationship between the area under the curve in the maximum voluntary squeeze pressure-time graph (AUC) and the HQ and Rintala's questionnaire (RQ). A statistically significant difference was found between HQ and RQ scores and high type and low type of ARMs. CONCLUSION: In our study, based on AM data, it was found that the use of HQ and RQ from the four SS we compared could be more effective in patients' follow-up. It was concluded that Peña's questionnaire and Krickenbeck's questionnaire should be used to determine the bowel management program of the patients rather than patients' follow-up. LEVELS OF EVIDENCE: Level II.

A New Approach to Tense End-to-End Anostomosis in Primary Surgical Repair of Esophageal Atresia: Vascularized Pleural Flap.

Background: Esophageal atresia (EA) is the most common congenital malformation of the esophagus. If the distance between the proximal and distal pouches is usually more than 2-3 cm, it is considered as long gap esophageal atresia (LGEA). In our study, it was planned to investigate the effect of the use of vascularized pleural flap (VPF) on postoperative recovery in cases with tense end-to-end anastomosis in the primary repair of LGEA. Methods: The postoperative recovery period data of patients who underwent tense end-to-end anastomosis due to LGEA between 01/01/2016 and 01/12/2020 in our clinic were analyzed retrospectively. Results: Between the specified dates, 37 patients were operated for EA. A tense end-to-end anastomosis was performed in 16 of 37 patients. In 5 of these patients, a VPF was placed on the anastomosis line. In the postoperative follow-up, no anastomotic leakage or anastomotic stenosis was observed in 5 patients who underwent tense anastomosis with VPF. In addition, it was observed that patients who underwent tense anastomosis with VPF were started oral nutrition earlier after surgery compared to patients without VPF. Conclusion: The success of the technique we performed in 5 patients without any complications suggested that this technique could be used as a method in tense anastomoses. It was thought that oral nutrition was initiated early in patients using VPF, since there was no anastomotic leak and the surgeon relied on the presence of the VPF.

Effect of bevacizumab and everolimus combination treatment on peritoneal sclerosis in an experimental rat model.

The aim of this study was to investigate whether bevacizumab and everolimus combination therapy is superior to bevacizumab treatment alone as a treatment for peritoneal sclerosis. Forty Wistar albino rats were divided into five equal groups. The control group received isotonic saline solution (2 mL/day) intraperitoneal (IP) daily for 3 weeks. The CG group received 2 mL 0.1% chlorhexidine gluconate (CG) and 15% ethanol dissolved in saline IP daily for 3 weeks. Peritoneal tissue samples were taken at the end of 3 weeks. The resting group received CG (weeks 0-3), plus isotonic saline solution (2 mL/day) IP daily and tap water (2 mL/day) via a feeding tube daily (weeks 3-6).The bevacizumab group received CG (weeks 1-3) plus bevacizumab at 2.5 mg/kg/day (2 mL) IP daily and tap water (2 mL/day) via a feeding tube daily (weeks 3-6). The bevacizumab+everolimus group received CG (weeks 1-3) plus bevacizumab at 2.5 mg/kg/day (2 mL) IP daily and everolimus at 0.3 mg/kg/day (2 mL) via a feeding tube daily (weeks 3-6). Peritoneal tissue samples were taken from these three groups at the end of 6 weeks and were examined after staining with hematoxylin-eosin and Masson's trichrome. Inflammation, vasculopathy, fibrosis, and peritoneal thickness were evaluated under light microscopy. The samples were also stained with anti-TGF-ß and anti-MMP-2. Inflammation and vasculopathy scores were significantly decreased in the VEGF-i group compared to the CG group. The addition of everolimus to VEGF-i showed significantly lower inflammation, vasculopathy, fibrosis scores, and an evident decrease in peritoneal thickening (respectively, 2.29 ± 0.76 vs 0.57 ± 0.53, P = .003; 2.71 ± 0.76 vs 1.43 ± 0.53, P = .008; 2.57 ± 0.79 vs 1.57 ± 0.79, P = .04; 247.5 ± 136.1 vs 84.5 ± 48.6, P = .048). MMP-2 levels were lower in the combination group compared to the resting group (2.63 ± 0.74 vs 1.86 ± 0.38, P = .019). The study results demonstrated that bevacizumab and everolimus combination therapy was more effective than bevacizumab therapy alone.

Pre-analytical protocol for measuring Alzheimer's disease biomarkers in fresh CSF.

INTRODUCTION: We aimed to establish a standardized, routine-use pre-analytical protocol for measuring Alzheimer's disease (AD) biomarkers in cerebrospinal fluid (CSF). METHODS: The effect of pre-analytical factors (sample collection/handling/storage/transportation) on biomarker levels was assessed using freshly collected CSF. Tube type/sterilization was assessed using previously frozen samples. A low-bind false-bottom tube (FBT, Sarstedt) was used for all experiments, except tube types/sterilization experiments. Biomarkers were measured using Elecsys CSF assays. RESULTS: Amyloid beta (Aß)1-42 levels varied by tube type, using a low-bind FBT reduced variation. Aß1-42 levels were higher with no mixing versus roller/inversion mixing. Aß1-42 levels were lower with horizontal versus upright transportation; this was resolved by maximal tube filling and storage at 2°C to 8°C. Aß1-40 levels were less strongly affected. Phospho-tau and total-tau levels were largely unaffected. DISCUSSION: We propose an easy-to-use, standardized, routine-use pre-analytical protocol, using low-bind FBTs, for measuring AD CSF biomarkers in clinical practice.

Testing pollution haven and pollution halo hypotheses for Turkey: a new perspective.

In this study, we analyzed the asymmetric short- and long-run causal links between foreign direct investments and emissions in Turkey over the time period 1974-2018. Using hidden co-integration techniques, we defined and tested the asymmetric pollution haven and asymmetric pollution halo hypotheses. To evaluate the long-run asymmetric causal relationship, we estimated both the crouching error correction model and vector error correction model. We performed a stepwise regression model to estimate the crouching error correction model. The empirical results confirmed an asymmetric causal relationship between positive shocks of foreign direct investments and positive movements in emissions in the short run as well as an asymmetric causal link between negative and positive shocks of foreign direct investments and positive emissions in the long run. Furthermore, the results showed that increases in foreign direct investments led to a decrease in the rate of emission growth in both the short and long run. This finding supports the validity of the asymmetric pollution halo hypothesis in Turkey's case. Policymakers should strengthen their environmental protection laws to protect the quality of their environments as well as implement policies that encourage the use of clean technology and tax incentives that increase foreign direct investment inflows. Graphical Abstract.

Peritonitis Due to Streptococcus Sanguinis in Automated Peritoneal Dialysis.

None.

Cardio-ankle vascular index is linked to deranged metabolic status, especially high HbA1c and monocyte-chemoattractant-1 protein, in predialysis chronic kidney disease.

INTRODUCTION AND PURPOSE: Arterial stiffness is an independent predictor of cardiovascular disease in chronic kidney disease (CKD). Cardio-ankle vascular index (CAVI) is a newly developed method used to assess arterial stiffness, independent of changes in blood pressure. CAVI reflects stiffness and atherosclerosis at the thoracic, abdominal, common iliac, femoral, and tibial artery levels. In predialysis stage 3-5 diabetic and nondiabetic CKD patients, CAVI levels and its relation to atherosclerosis-associated risk factors including monocyte-chemoattractant protein-1 (MCP-1), sclerostin, fibroblast growth factor-23 (FGF-23), Klotho, and 25-OH vitamin D were determined. MATERIALS AND METHODS: The study was performed on three age-matched and gender-matched groups. Group 1 included 46 stage 3-5 nondiabetic CKD patients, group 2 included 44 stage 3-5 diabetic CKD patients, and group 3 included 44 non-uremic controls. All subjects underwent CAVI measurement. Serum glycated hemoglobin (HbA1c), total calcium, phosphorus, parathormone, FGF-23, Klotho, MCP-1, sclerostin, and 25-OH vitamin D were determined using standard methods. RESULTS: CAVI level was 8.22 ± 0.18 m/s in diabetic CKD patients and significantly higher than in nondiabetic CKD (7.61 ± 0.18 m/s) and control (7.59 ± 0.17 m/s) patients. FGF-23 level was higher in the CKD groups than controls but not statistically significant. MCP-1 level was significantly higher in diabetic CKD patients. Klotho and sclerostin levels were significantly lower in diabetic CKD patients. In the whole cohort, CAVI showed positive correlations with age (r = 0.447, p < 0.0001), smoking (r = 0.331, p = 0.035), mean arterial blood pressure (MABP; r = 0.327, p < 0.0001), fasting blood glucose (r = 0.185, p = 0.033), and HbA1c (r = 0.258, p = 0.003). Stepwise regression analysis revealed that age (p = 0.0001, B = 0.461), MABP (p < 0.0001, B = 0.365), HbA1c (p = 0.003, B = 0.251), and MCP-1 (p = 0.013, B = 0.214) independently predicted CAVI levels. CONCLUSION: Our results indicate higher CAVI levels, therefore, resulting in increased arterial stiffness in the setting of diabetic CKD. Apart from age and MABP, deranged metabolic status, especially increased HbA1c and MCP-1 levels, is also independently associated with increasing CAVI levels in CKD patients. These results emphasize the importance of metabolic control in the development of arterial stiffness in CKD patients, which is an early predictor of developing cardiovascular complications.

Hamartoma mesenquimal rabdomiomatoso en una ubicación inesperada / Rhabdomyomatous mesenchymal hamartoma developed at an unexpected location

El hamartoma mesenquimal rabdomiomatoso es una lesión cutánea rara descripta por primera vez en 1986 como "hamartoma de músculo estriado". En general, se presenta en la región de la cabeza y el cuello de los recién nacidos. En este artículo, describimos el caso de una niña de 38 días con un apéndice cutáneo congénito en la región perianal. En el examen físico, no se observaron anomalías congénitas ni otras lesiones cutáneas. En el examen histopatológico, se observó un hamartoma con fibras de músculo esquelético desorganizadas. El diagnóstico diferencial incluyó apéndice cutáneo, trago accesorio y fibroma péndulo. El hamartoma mesenquimal rabdomiomatoso se diferencia de las lesiones mencionadas debido al componente de músculo estriado. Dado que no conlleva el riesgo de recurrencia ni de transformación a neoplasia maligna, no es muy relevante diferenciarlo de estas lesiones. Sin embargo, es importante establecer el diagnóstico correcto porque aproximadamente un tercio de los casos se asocian con anomalías congénitas. Asimismo, es necesario un diagnóstico histopatológico en los niños con ubicación perianal debido a las manifestaciones clínicas similares al rabdomiosarcoma.

Rhabdomyomatous mesenchymal hamartoma is a rare dermal lesion which was first described in 1986 as "striated muscle hamartoma". It usually develops in the head and neck region of newborns. We report a 38-day-old girl with a congenital skin tag in the perianal region. Physical examination did not reveal any congenital abnormalities or other dermal lesions. Histopathological examination showed a hamartoma with disorganized skeletal muscle fibers. The differential diagnosis includes skin tag, accessory tragus and soft fibroma. Rhabdomyomatous mesenchymal hamartoma differs from the listed lesions with its striated muscle component. Since it does not carry the risk of recurrence and malignant transformation, it is not very important to distinguish it from these lesions. However, a correct diagnosis is important because approximately one third of the cases are associated with congenital anomalies. Also, histopathological diagnosis should be made in children with perianal localization due to similar clinical manifestation of rhabdomyosarcoma.

Rhabdomyomatous mesenchymal hamartoma developed at an unexpected location. / Hamartoma mesenquimal rabdomiomatoso en una ubicación inesperada.

Rhabdomyomatous mesenchymal hamartoma is a rare dermal lesion which was first described in 1986 as "striated muscle hamartoma". It usually develops in the head and neck region of newborns. We report a 38-day-old girl with a congenital skin tag in the perianal region. Physical examination did not reveal any congenital abnormalities or other dermal lesions. Histopathological examination showed a hamartoma with disorganized skeletal muscle fibers. The differential diagnosis includes skin tag, accessory tragus and soft fibroma. Rhabdomyomatous mesenchymal hamartoma differs from the listed lesions with its striated muscle component. Since it does not carry the risk of recurrence and malignant transformation, it is not very important to distinguish it from these lesions. However, a correct diagnosis is important because approximately one third of the cases are associated with congenital anomalies. Also, histopathological diagnosis should be made in children with perianal localization due to similar clinical manifestation of rhabdomyosarcoma.

El hamartoma mesenquimal rabdomiomatoso es una lesión cutánea rara descripta por primera vez en 1986 como "hamartoma de músculo estriado". En general, se presenta en la región de la cabeza y el cuello de los recién nacidos. En este artículo, describimos el caso de una niña de 38 días con un apéndice cutáneo congénito en la región perianal. En el examen físico, no se observaron anomalías congénitas ni otras lesiones cutáneas. En el examen histopatológico, se observó un hamartoma con fibras de músculo esquelético desorganizadas. El diagnóstico diferencial incluyó apéndice cutáneo, trago accesorio y fibroma péndulo. El hamartoma mesenquimal rabdomiomatoso se diferencia de las lesiones mencionadas debido al componente de músculo estriado. Dado que no conlleva el riesgo de recurrencia ni de transformación a neoplasia maligna, no es muy relevante diferenciarlo de estas lesiones. Sin embargo, es importante establecer el diagnóstico correcto porque aproximadamente un tercio de los casos se asocian con anomalías congénitas. Asimismo, es necesario un diagnóstico histopatológico en los niños con ubicación perianal debido a las manifestaciones clínicas similares al rabdomiosarcoma.

Interrelationships among foreign direct investments, renewable energy, and CO2 emissions for different European country groups: a panel ARDL approach.

This study estimated unbalanced panel data analysis to investigate the relationship among CO2 emissions, GDP, renewable and non-renewable energy utilization, and foreign direct investment (FDI) inflow in 26 European countries. Moreover, we investigated the role of environmental regulations in validation of the pollution haven hypothesis (PHH) in two EU country groups, namely 1-4th and 5th enlargement countries of EU, since their adaptation periods of environmental legislation may indicate differences. Empirical results confirmed the validation of environmental Kuznets curve (EKC) hypothesis and PHH for overall EU countries. However, results differ between country groups in EU. For example, while results confirm the evidence of EKC in 5th enlargement countries, they do not support in 1-4th enlargement countries. Moreover, while environmental regulations do not play an important role in the validity of PHH, they are important factors in the validity of EKC in overall EU countries. Granger causalities showed that economic growth causes energy consumption and FDI inflow. Since renewable energy mitigates the emissions, EU countries should enhance green technology and energy efficiency to ensure sustainable development. What is more, EU countries need to tighten the environmental regulations on FDI inflow. Therefore, our results support the new framework by European Commission on screening the FDI inflows throughout the EU zone.

Compositional data analysis in epidemiology.

Compositional data analysis refers to analyzing relative information, based on ratios between the variables in a data set. Data from epidemiology are usually treated as absolute information in an analysis. We outline the differences in both approaches for univariate and multivariate statistical analyses, using illustrative data sets from Austrian districts. Not only the results of the analyses can differ, but in particular the interpretation differs. It is demonstrated that the compositional data analysis approach leads to new and interesting insights.

Do foreign direct investment and renewable energy consumption affect the CO2 emissions? New evidence from a panel ARDL approach to Kyoto Annex countries.

This study examines the impact of foreign direct investment (FDI) and the potential of renewable energy consumption on carbon dioxide (CO2) emissions in 21 Kyoto countries using an unbalanced panel data. For this purpose, Environmental Kuznets Curve (EKC) hypothesis was tested using panel cointegration analysis. Panel causality tests show that there are significant long-run causalities from the variables to carbon emissions, renewable energy consumption, fossil fuel energy consumption and inflow foreign direct investments. The results of our model support the pollution haloes hypothesis which states that FDI brings in clean technology and improves the environmental standards. However, an inverted U-shaped relationship (EKC) was not supported by the estimated model for the 21 Kyoto countries. This means that economic growth cannot ensure environmental protection itself or environmental goals cannot await economic growth. Another important finding is that renewable energy consumption decreases carbon emissions. Based on the empirical results, some important policy implications emerge. Kyoto countries should stimulate the FDI inflows and usage of renewable energy consumption to mitigate the air pollution and meet the emission targets. This paper provides new insights into environment and energy policies through FDI inclusion.

Error Propagation in Isometric Log-ratio Coordinates for Compositional Data: Theoretical and Practical Considerations.

Compositional data, as they typically appear in geochemistry in terms of concentrations of chemical elements in soil samples, need to be expressed in log-ratio coordinates before applying the traditional statistical tools if the relative structure of the data is of primary interest. There are different possibilities for this purpose, like centered log-ratio coefficients, or isometric log-ratio coordinates. In both the approaches, geometric means of the compositional parts are involved, and it is unclear how measurement errors or detection limit problems affect their presentation in coordinates. This problem is investigated theoretically by making use of the theory of error propagation. Due to certain limitations of this approach, the effect of error propagation is also studied by means of simulations. This allows to provide recommendations for practitioners on the amount of error and on the expected distortion of the results, depending on the purpose of the analysis.