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Volume : 35 Issue : 3 Year : 2020



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Medeniyet Med J: 35 (3)
Volume: 35  Issue: 3 - 2020
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1.Cover

Page I

2.Contents

Pages II - III

3.Editorial Board

Pages IV - VI

4.Publication Policies and Writing Guide

Pages VII - IX

ORIGINAL ARTICLE
5.Delayed Gastric Emptying as a Complication of Whipple’s Procedure: Could it be Much Less Frequent than Anticipated? Could the Definition Be Revised? A Single Center Experience
Mikail Çakır, Muzaffer Akıncı, Okan Murat Aktürk
doi: 10.5222/MMJ.2020.02222  Pages 181 - 187
Amaç: Periampuller tümörler için Whipple prosedürünün önemli riskleri ve komplikasyonları vardır. Gecikmiş mide boşalması en yüksek orana sahiptir. Uluslararası Pankreas Cerrahisi Çalışma Grubu (ISGPS) bunu tanımlasa da, otörler arasında çok sayıda tanım hala mevcuttur. Bu çalışma tanımı revize etmeyi amaçlamaktadır.
Yöntem: 73 ardışık hasta, özellikle gecikmiş mide boşalması olmak üzere komplikasyonlar açısından analiz edildi. Tüm hastalara standart bir ameliyat uygulandı. Total pankreatektomili ve benign hastalıkların olduğu prosedürler hariç tutuldu.
Bulgular: Toplam 73 hasta çalışmaya dahil edildi. 15 (%20,6) hastada intraabdominal komplikasyon görüldü. Sadece bir (%1,4) hastada Grade C gecikmiş mide boşalması gözlendi. Grade A ve B ise üç (%4,1) hastada gözlendi, bu hastalar konzervatif yöntemlere iyi yanıt verdiler ve ekstra morbidite görülmedi.
Sonuç: Grade A ve B gecikmiş mide boşalması herhangi bir gastrointestinal cerrahi sonrası görülebilmektedir. Bu hastalar nazogastrik tüp yerleştirilmesi ile basit konzervatif yöntemlere iyi yanıt verir. Karın içi koleksiyonun drenajı, varsa boşalma sorununu çözer. Diğer intraabdominal komplikasyonlar olmaksızın sadece grade C bu prosedürün bir komplikasyonu olarak kabul edilebilir. ISGPS tanımı nedeni içermiyor. Dolayısıyla tanım ve derecelendirme revize edilebilir.
Objective: Whipple’s procedure for periampullary tumors has significant risks and complications. Delayed gastric emptying has the highest rate. Although the International Study Group of Pancreatic Surgery defined (ISGPS) this entity, multiple definitions still exist among authors. This study aims to revise the definition.
Method: Seventy-three consecutive patients were analyzed for complications, particularly delayed gastric emptying. All patients underwent a standardized surgery. Procedures used for total pancreatectomies and benign diseases were excluded.
Results: A total of 73 patients were included in the study. Intra-abdominal complications were observed in 15 (20.6%) patients. Grade C delayed gastric emptying was observed in only one (1.4%) patient. Grade A and B disease were observed in three (4.1%) patients. However, they responded well to conservative methods, causing no extra morbidity.
Conclusion: Grade A and B delayed gastric emptying can be observed after any gastrointestinal surgery. These patients respond well to simple conservative methods with nasogastric intubation. Drainage of the intra-abdominal collection resolves the emptying problem (if any). Only grade C disease without other intra-abdominal complications can be accepted as a complication of this procedure. ISGPS definition does not include the cause. Thus, the definition and grading can be revised.

6.Knowledge, Attitude And Practice On Diabetic Wound Care Management Among Healthcare Professionals And Impact From A Short Course Training In Sabah, Borneo.
Melvin Ebin Bondi, Syed Sharizman Syed Abdul Rahim, Richard Avoi, Firdaus Hayati, Fatimah Ahmedy, Azizan Omar, Mohammad Saffree Jeffree, Awang Setia Musleh
doi: 10.5222/MMJ.2020.02929  Pages 188 - 194
Objective: Healthcare professionals with an advanced level of knowledge and skills on diabetic wound care management are needed to effectively manage complex wounds. This study aimed to determine the effects of an educational intervention to enhance the management of wound care among healthcare professionals.
Method: This study was part of a quasi-experimental pre-post research design where 82 healthcare professionals were recruited and assigned to intervention and control groups. The participants in the intervention group attended two days of educational intervention training on diabetic wound care management, while there was no intervention in the control group. A questionnaire on knowledge, attitude, and practice was applied before and one-month post-intervention to both groups.
Results: Pre-test resulted in a low level of knowledge 72.1% and 74.4%, negative level of attitude 67.4% and 66.7%, and a moderate level of practice 79.1% and 76.9% in both intervention and control groups respectively. Post-test resulted in increasing levels of knowledge (76.7%), positive attitude (100%), and practice (76.7%) in the intervention group. At the same time, there was no significant change in the control group. Repeated Measure ANOVA for within-subject and between-subject effects resulted in a statistically significant p-value of 0.001 for knowledge, attitude, and practice after the educational intervention.
Conclusion: Health professionals have only a moderate level of knowledge on diabetic wound care management. It is important to improve this level by specific trainings and by using a good training module.

7.Is There Any Relationship Between Thyroid Function Abnormalities, Thyroid Antibodies and Gestational Diabetes Mellitus (GDM) Development in Pregnant Women?
Umit Yasemin Sert, Gül Nihal Buyuk, Yaprak Engin-Ustun, A. Seval Ozgu-Erdinc
doi: 10.5222/MMJ.2020.29964  Pages 195 - 201
Objective: To determine the levels of thyroid-stimulating hormone (TSH), thyroxin (T4), triiodothyronine (T3), anti-thyroid peroxidase (anti-TPO), anti-thyroglobulin (anti-TG) and renal iodine excretion (RIE) in the first trimester of the pregnancy and to estimate the risk of developing GDM in these patients.
Method: The levels of TSH, T3, T4, anti-TPO, anti-TG, and RIE were retrospectively evaluated. A total of 312 pregnant women were included in the study (GDM (-) group n=240, GDM (+) group n=62). Diagnosis of GDM was made according to the recommendation of American Diabetes Organization (ADA). The association between thyroid dysfunction and GDM was evaluated.
Results: Our study included a total of 302 women. Sixty-two of these women were diagnosed as GDM (62/302=20.5%). When compared with the GDM (-) group the mean TSH level (2.02 vs 4.13 p=0.019), anti-TPO positivity (8.3% vs 30.64% p=0.044), anti-TG positivity (8.3% vs 19.4% p=0.019) and RIE (156 vs 178 p=0.017) were significantly higher in the GDM (+) group. TSH levels were statistically significantly higher in patients with positive anti-TPO levels (P=0.045).
Conclusion: Elevated TSH levels, TPO and TG antibody positivity rates were more frequent among the patients with GDM. These results may be a guide to perform routine thyroid function tests for patients with increased risk of GDM, on the other hand, they will alert the physicians for GDM progression and ensure taking preventive attempts for the patients who have thyroid disorder, especially those with positive thyroid antibodies in the first trimester of the pregnancy.
Objective: To determine the levels of thyroid-stimulating hormone (TSH), thyroxin (T4), triiodothyronine (T3), anti-thyroid peroxidase (anti-TPO), anti-thyroglobulin (anti-TG) and renal iodine excretion (RIE) in the first trimester of the pregnancy and to estimate the risk of developing GDM in these patients.
Method: The levels of TSH, T3, T4, anti-TPO, anti-TG, and RIE were retrospectively evaluated. A total of 312 pregnant women were included in the study (GDM (-) group n=240, GDM (+) group n=62). Diagnosis of GDM was made according to the recommendation of American Diabetes Organization (ADA). The association between thyroid dysfunction and GDM was evaluated.
Results: Our study included a total of 302 women. Sixty-two of these women were diagnosed as GDM (62/302=20.5%). When compared with the GDM (-) group the mean TSH level (2.02 vs 4.13 p=0.019), anti-TPO positivity (8.3% vs 30.64% p=0.044), anti-TG positivity (8.3% vs 19.4% p=0.019) and RIE (156 vs 178 p=0.017) were significantly higher in the GDM (+) group. TSH levels were statistically significantly higher in patients with positive anti-TPO levels (P=0.045).
Conclusion: Elevated TSH levels, TPO and TG antibody positivity rates were more frequent among the patients with GDM. These results may be a guide to perform routine thyroid function tests for patients with increased risk of GDM, on the other hand, they will alert the physicians for GDM progression and ensure taking preventive attempts for the patients who have thyroid disorder, especially those with positive thyroid antibodies in the first trimester of the pregnancy.

8.A Retrospective Clinical Analysis Of Hypertermic Intraperitoneal Chemotherapy In Gynecological Cancers: Technıcal Detail, Tolerability And Efficacy
Yagmur Minareci, Özgür Aydın Tosun, Hamdullah Sözen, Samet Topuz, Mehmet Yavuz Salihoğlu
doi: 10.5222/MMJ.2020.31855  Pages 202 - 211
Amaç: Bu çalışmanın amacı, ağırlıklı olarak platine dirençli hastalardan oluşan epitelyal over kanserli ve endometriyal kanserli hastalarda sitoredüktif cerrahi (SRC) esnasında yapılan HİPEK işleminin sonuçlarını ortaya koymaktır.
Yöntem: Mayıs 2015-0cak 2020 arasında SRC sonrası HİPEK uygulanan hastaların bilgileri retrospektif olarak değerlendirildi. Cerrahi komplikasyonlar, Clavien-Dindo sınıflamasına göre sınıflandırıldı.
Bulgular: 32 hastaya SRC+HİPEK uygulandı. Tedavinin uygulandığı hastalardan 2 tanesi endometriyum kanseriydi. Epitelyal over kanseri olan 30 hastanın 5 tanesine interval SRC+HİPEK yapıldı. Nüks epitelyal over kanseri olan 25 hastaya ise sekonder SRC+HİPEK uygulandı. Nüks epitelyal over kanserli 18 hasta platine dirençliydi. Retrospektif olarak operasyona bağlı mortalite %3 ve ciddi morbidite %12 olarak saptandı Epitelyal over kanseri olan 30 hastanın ortance takip süresi 15 ay idi. Kaplan-Meier sağkalım l istatistik testine göre 1 yıllık toplam sağkalım %69 ve hastalıksız sağkalım %30.3 olarak hesaplandı.
Sonuç: SRC+HİPEK prosedürünün kabul edilebilir ciddi morbidite ve mortalite oranları vardır. Öte yandan, tam sitoredüktif cerrahi geçiren nüks epitelyal over kanserli hastaların genel sağkalımlarının sayısal olarak daha uzun olduğu ancak bunun istatistiksel olarak anlamlı olmadığı görülmüştür. SRC esnasında HİPEK uygulaması, platine dirençli epitelyal over kanseri kohortunda olumsuz sonuçlarla ilişkili bulunmamıştır. Mevcut çalışmanın kısa dönem sonuçları umut vericidir.
Objective: The aim of this study was to reveal the results of hyperthermic intraperitoneal chemotherapy (HIPEC procedure) performed during cytoreductive surgery (CRS) in patients with endometrial cancer and epithelial ovarian cancer which included mainly platinum-resistant patients.
Method: Patients who underwent CRS+HIPEC between May 2015 and January 2020 were evaluated retrospectively. Surgical complications were graded according to the Clavien-Dindo classification.
Results: A total of 33 CRS+HIPEC procedures were performed in 32 patients, two of whom had recurrent endometrial cancer. Of the 30 patients with epithelial ovarian cancer (EOC), five underwent interval CRS+HIPEC, and remaining 25 patients underwent secondary CRS+HIPEC treatment due to relapsed disease. Eighteen of the patients with relapsed disease were platinum-resistant. The overall operative mortality and severe morbidity rates were %3 and 12%, respectively. For 30 patients with EOC, during a median follow-up period of 15 months, Kaplan-Meier survival analysis revealed a 1-year OS and PFS rates of 69.7% and 30.3%, respectively. Moreover, in the subgroup analysis of the platinum-resistant cohort, median OS and PFS were 14 and five months, respectively.
Conclusion: CRS+HIPEC procedures had acceptable severe morbidity and mortality rates. In addition, patients with recurrent EOC and without a visible residual disease at the end of cytoreductive surgery had, though not statistically significant, longer OS. HIPEC administration during CRS was not associated with adverse outcomes in the platinum-resistant EOC cohort. The short-term results of the current study are promising.

9.Serum Glial Fibrillary Acidic Protein: A Surrogate Marker of the Activity of Multiple Sclerosis
Inas K. Sharquie, Gheyath Al Gawwam, Shatha F. Abdullah
doi: 10.5222/MMJ.2020.48265  Pages 212 - 218
Objective: Multiple sclerosis (MS) is a neurodegenerative disorder with various clinical types. Glial fibrillary acidic protein (GFAP) is significantly elevated in the cerebrospinal fluid (CSF) of MS patients compared with that of healthy controls. The aim of this study is to evaluate serum levels of GFAP in relation to disease activity in relapsing-remitting MS patients and to compare them with those of healthy controls.
Method: This study involved 58 MS patients of relapsing-remitting MS (RRMS) type, 22 in an active stage of the disease and 36 in remission, and 50 healthy individuals as age- and sex-matched controls. Blood samples were taken from the patients at the MS Clinic of the Baghdad Teaching Hospital, and the serum levels of GFAP were determined using the enzyme-linked immunosorbent assay (ELISA) technique.
Results: Mean GFAP serum levels in 22 patients presenting in the active state of the disease (6.47±3.39 ng/ml) and 36 cases in remission were (5.33±2.82 ng/ml) (p=0.074) were determined as indicated. When RRMS patients (n=58) were compared with the healthy controls (n=50, 1.89±1.21), the difference in serum levels of GFAP was statistically significant (p<0.001). The area under the curve of the serum measures of GFAP obtained through the receiver operating characteristics was 0.903, which was also statistically significant (p<0.001).
Conclusion: GFAP biomarker is an indicator of disease activity in RRMS patients, and its serum level may correlate with the state of remission or exacerbation.

10.A Five-Year Retrospective Analysis of Basal Cell Carcinoma: A Monocentric Study
Seyma Özkanlı, Tuce Söylemez, Havva Keskin, Hatice Seneldir, Fatıma Müberra Şahin, Ayşenur Çetinkaya, Andaç Göktürk, Nagihan Ayçiçek, Kübra Düz, Bengü Çobanoğlu Şimsek
doi: 10.5222/MMJ.2020.92332  Pages 219 - 225
Amaç: Bu çalışmada amacımız göç almasından dolayı bütün ülke genelini yansıtan karışık insan populasyonuna sahip İstanbul’da Bazal Hücreli Karsinom (BHK) vakalarının histopatolojik alt tiplerinin, vücutta dağılım bölgelerinin, tek ve multiple görülme oranlarının belirlenmesidir.
Yöntem: 2014-2018 yılları arasında 896 BHK vakası ile ilgili verileri retrospektif olarak analiz ettik. Hastaların yaşı, cinsiyeti, tümör çapı, tümör lokalizasyonu, histolojik tip, ülserasyon, lenfovasküler/perinöral invazyon ve multiple tümör varlığı hastanenin ve patoloji kliniğinin arşiv kayıtlarından elde edildi.
Bulgular: Tek değişkenli analizde yaş, tümör boyutu ve multiple tümör varlığı cinsiyet ile anlamlı olarak ilişkili bulunmuştur (sırasıyla p=0,011, p=0,001 ve p=0,021). Ayrıca, yaş, erkek cinsiyet ve tümör boyutu multiple tümör varlığıyla anlamlı olarak ilişkiliydi (sırasıyla p=0,003, p=0,021 ve p=0,001). BHK erkeklerde daha yaygın ve BHK çaplarının da erkek hastalarda daha büyük olduğu gözlendi. Multiple tümörler, yaşlı ve erkek hastalarda daha sık görüldü. Bu tümörler yine bu gruplarda daha büyük çaplara sahipti. Nodüler BHK tipi tüm yaş gruplarında en sık görülen tip olarak bulundu.
Sonuç: Çalışmamız, Türkiye’de en fazla vakaya sahip olan ilk BHK çalışması olması ve İstanbul, Türkiye’nin nüfusunu yansıtıyor olmasından dolayı, Türkiye’deki BHK vakalarının verileri için önemlidir.
Objective: Our aim in this study is to define the histopathological subtypes, body site distribution, and incidence rates of single or multiple of BCCs. The study is conducted on patients from a single institution in Istanbul which has a migrant-receiving population reflecting that of the country overall.
Method: We retrospectively analyzed data concerning 896 cases of BCC seen between 2014 and 2018. Data about patient demographics (age and sex), tumor diameter,its anatomic localization, histological type, presence of ulceration, lymphovascular/perineural invasion, and single or multiple tumor formations were retrieved from both the hospital’s automated system and archived records of the pathology clinic.
Results: Our univariate analysis showed that the patients’ age, tumor size, and tumor multicentricity were all significantly related to their gender (p=0.011, p=0.001, and p=0.021, respectively). Further, age, male gender, and tumor size were all significantly related to tumor (p=0.003, p=0.021, and p=0.001, respectively). BCC was most commonly found in male, and the diameters of the BCC tumors were also larger in male patients. Multiple BCC was more frequently seen in older and male patients, and the tumors had larger diameters in these groups. The nodular type of BCC was the most frequently seen type in all age groups.
Conclusion: As our study is the first BCC study that has the greatest number of cases in Turkey and as Istanbul reflects the population of Turkey, it is important for the data of BCC cases in Turkey.

11.Effect Of Temperament Characteristics On Depression-Anxiety Level And Quality Of Life In Infertile Women
Selen Işık Ulusoy, Eser Çolak
doi: 10.5222/MMJ.2020.96646  Pages 226 - 235
Amaç: İnfertil kadınlarda anksiyete bozuklukları ve depresyon riskinin arttığı ve yaşam kalitesinin bozulduğu bilinmektedir. Mizaç özellikleri ise duygudurum bozukluklarının öngörücüsü olarak kabul edilmektedir. Bu çalışmanın amacı infertil kadınlardaki mizaç özelliklerini ve depresyon, anksiyete düzeyi ile yaşam kalitesi üzerine etkilerini inceleyerek, sağlıklı kadınlara göre farklarının ve ilişki düzeyinin ortaya koyulmasıdır.
Yöntem: Çalışmaya primer infertilite tanısı almış 44 kadın hasta ve 30 sağlıklı kadın kontrol dahil edildi. Katılımcıların mizaç özellikleri, Memphis, Pisa, Paris ve San Diego Mizaç Değerlendirme Anketi (TEMPS-A) ile değerlendirildi. Depresyon ve anksiyete şiddeti Beck Depresyon Envanteri (BDE) ve Beck Anksiyete Envanteri (BAE) ile değerlendirildi. Ayrıca yaşam kalitesini değerlendirmek için Kısa Form 36 (SF-36) yaşam kalitesi ölçeği uygulandı.
Bulgular: İnfertil kadınlarda hipertimik mizaç özellikleri kontrol grubuna göre daha yüksekti (p=0,001). BDE puanları depresif ve siklotimik mizaç puanları ile pozitif, BAE puanları ise depresif ve anksiyöz mizaç puanları ile pozitif korelasyon gösterdi. Hipertimik mizaç ile BAE ve BDE puanları arasında negatif korelasyon bulundu. Hipertimik mizaç puanları, yaşam kalitesi ölçeğinin hem fiziksel hem de zihinsel alt boyut puanları ile pozitif korelasyon gösterdiği saptandı.
Sonuç: Bu çalışmada infertil kadınlarda hipertimik mizaçın anksiyete ve depresyondan koruyucu olduğu; yaşam kalitesini arttırdığı gösterilmiştir. Hipertimik mizaç ile ovaryan hormonlar ya da biyolojik parametreler arasındaki ilişkinin aydınlatılması için ek çalışmalara ihtiyaç vardır.ması için ek çalışmalara ihtiyaç vardır.
Objective: It is known that the risk of anxiety disorders and depression in infertile women increases and their quality of life deteriorates. Temperamental characteristics are considered as predictors of mood disorders. The aim of this study was to investigate temperamental characteristics in infertile women and their effects on depression and anxiety levels, and the quality of life, and to reveal the differences and level of relationship compared to healthy women.
Method: Fourty-four female patients with primary infertility and 30 healthy female controls were included in this study. Temperamental characteristics of the participants were assessed with Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version (TEMPS-A). Depression and anxiety severity were evaluated with Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). To evaluate the quality of life, Short Form 36 (SF-36) health survey questionnaire was also applied.
Results: Hyperthymic temperament scores were higher in infertile women than the control group (p=0.001). BDI scores were positively correlated with depressive and cyclothymic temperament scores, and BAI scores were positively correlated with depressive and anxious scores. A negative correlation was found between hyperthymic temperament and BAI and BDI scores. Hyperthymic temperament scores were positively correlated with both physical and mental subdimension scores of the quality of life scale.
Conclusion: In this study, hyperthymic temperament in infertile women was shown to be protective against anxiety and depression and it also improves the quality of life. Additional studies are needed to clarify the relationship between hyperthymic temperament and ovarian hormones or other biological parameters.

12.Obesogenic Environment in Childhood: Implications of High Socioeconomic Level in a Developing Country
Sibel Hatice Özümüt, Müferet Ergüven, Esen Besli
doi: 10.5222/MMJ.2020.99836  Pages 236 - 241
Amaç: Günümüzde özellikle gelişmiş ülkelerde çocuk yaşlardaki şişmanlık önemli bir sağlık problemi olarak ele alınmaktadır. Bu çalışma, çocuklarda obezite sıklığını belirleyebilmeyi ve çocuklarda televizyon izleme alışkanlığının, bilgisayar kullanımının ve sosyoekonomik durumun obezite ile ilişkisini ortaya koymayı amaçlamaktadır.
Materyal ve metod: İstanbul’da tesadüfi örnekleme ile seçilen 11 tane devlete ait ilköğretim okulunda kesitsel bir araştırma yapıldı. Araştırmaya 767 erkek (% 51.9), 712 kız (% 48.1) olmak üzere toplam1479 öğrenci katıldı. Yaşları 10-15 arasında değişmekte olup, ortalama yaş kızlarda 11.95±1.36 yıl, erkeklerde 12.06±1.39 yıldı. Yapılandırılmış anket formu ile demografik özellikler ve obezitede etkili olan faktörler sorgulandı. Öğrencilerin boy ve kiloları ölçüldü ve beden kitle indeksi (BMI) hesaplandı. BMI 95. persantilin üzerinde olanlar şişman olarak, 85-95 persantilleri arası hafif şişman (overweight) olarak kabul edildi.
Sonuçlar: Araştırma grubunda obezite oranı %5.3, hafif şişman oranı %14.9 olarak saptandı. Obez ve hafif şişman toplam sıklığı %20.2 bulundu. Sosyoekonomik düzeyin yüksek olduğu grupta obezite sıklığı kız ve erkek cinste de anlamlı yüksek olarak belirlendi. (p< 0.01) Obezite risk faktörlerinde ana belirleyici olarak sosyoekonomik durum saptandı.
Ortalama televizyon izleme ve bilgisayar kullanma süresi 3.74±1.58 saatti. Bu sürenin 5 saatin üzerinde olduğunda obezite riskinin 3 kat arttığı saptandı. Lojistik regresyon analizinde sosyoekonomik düzey ana belirleyici olarak saptanırken, televizyon izleme ve bilgisayar kullanım süresinin obeziteye etkisi sınırda anlamlı olarak bulundu. (p<0.045)
Tartışma: Yüksek sosyoekonomik duruma sahip ailelerin yaşam tarzı adölesanlarda obezite için ana belirleyicidir. Daha yüksek kalorili gıdalar ile beslenme, daha çok media kullanımı ve bunun getirdiği daha sedanter yaşam yüksek sosyoekonomik durumun oluşturduğu obesojenik bir çevredir. Obezite için çevresel risk faktörleri belirlenmelidir.
Objective: The objective of this study is to determine the frequency of obesity among students between 10-15 years of age and to evaluate the relationships between daily screen time and socioeconomic level and obesity in children.
Methods: A cross-sectional study was performed in 11 state schools selected with random sampling in Istanbul. Demographic characteristics and factors affecting obesity were inquired with the structured questionnaire form and Body Mass Indexes were calculated.
Results: A total of 1479 students (767males (51.9%)) were included in the study. The total prevalence of overweight and obese children was 20.2%. The frequency of obesity in the high socioeconomic level group was significantly higher than low one (p< 0.01).
The average daily screen time was 3.74±1.58 hours. The obesity risk is found to increase 3 times when this period exceeded 5 hours. In the logistic regression analysis, while high socioeconomic level was found as the main determinant among the risk factors for obesity, the effects of daily screen time were found to be marginally significant (p<0.045).
Conclusion: Lifestyles of families with high socioeconomic status are the main determinant of obesity in adolescents. Environmental risk factors for obesity should be assessed taking national characteristics into account.

REVIEW
13.Coronavirus-2019 Disease (COVID-19) in children
Fahri Ovalı
doi: 10.5222/MMJ.2020.77675  Pages 242 - 252
COVID-19, tüm yaş gruplarını etkiler ancak çocuklarda ağır vakalar genellikle azdır ve mortalite çok düşüktür. Birçok durumda çocuklar hastalığı ebeveynlerinden veya yakın çevresinden alırlar. Çocuklarda hastalığın neden hafif geçtiği tam olarak bilinmemektedir ancak ACE2 reseptörlerinin fazla oluşu, immün sistemlerinin tam olarak gelişmemiş olması, sık görülen diğer viral ajanlarla çapraz reaksiyon olması, fetal hemoglobinin koruyucu olması, ev dışında daha az zaman geçirmeleri ve daha az seyahat etmeleri, sigara ve hava kirliliğine maruz kalmamaları etkili olabilir. Birçok vaka asemptomatik olmasına rağmen virusü etrafa bulaştırabilirler. Anneden fetusa vertikal geçiş gösterilememiştir. Semptomatik hastalarda ateş ve solunum sistemi bulgularını ishal ve kusma izler. COVID-19 ile Kawasaki hastalığı arasında ilişki olabileceğini gösteren bulgular vardır. Yenidoğanlardaki bulgular ve tanısal testler büyük çocuklardakine benzerdir. Çocuklardaki esas tedavi şekli destek tedavisidir ve birçok hastada antiviral tedaviye gerek yoktur. Sitokin fırtınasının geliştiği durumlarda anti-inflamatuar tedaviler yapılabilir. Anne sütünde virus gösterilememiştir, bu yüzden anneler tüm önlemleri aldıktan sonra bebeklerini emzirmelidir. Bu dönemde çocukların rutin aşılanması ihmal edilmemelidir. Evde kalmak zorunda kalan çocuklara ve sağlık personeline psikolojik destek yapılmalıdır.
COVID-19 disease affects all ages, but severe cases of the disease and mortality are very rarely seen among children. In most cases, they acquire the virus from their parents or from an another infected person. The exact reasons why the disease has a milder course in children is unknown but high numbers of Angiotensin Converting Enzyme-2 (ACE2) receptors, underdeveloped immune responses, cross-reaction with other viruses, protective effect of fetal hemoglobin and fewer outdoor activities as well as journeys, and nonexposure to air pollution, and smoking. Although many cases are asymptomatic, they can still shed the virus. Materno-fetal vertical transmission has not been shown so far. In symptomatic cases, clinical findings include fever and respiratory symptoms, followed by diarrhea and vomiting. There are signs indicating a possible association between Kawasaki disease and COVID-19. Clinical findings and diagnostic procedures in newborns, and older children are similar. Supportive therapy is essential and antiviral agents are not required in most cases. During cytokine storm, anti-inflammatory treatments may be tried. There is no evidence for transmission through breastmilk; therefore infected mothers should breastfeed their infants by taking all precautions. Routine immunizations of children should not be deferred during COVID-19 outbreak period. Psychological support for children who need to stay at home and for healthcare personnel should be provided.

14.Mutations Observed in the SARS-CoV-2 Spike Glycoprotein and Their Effects in the Interaction of Virus with ACE-2 Receptor
Bengül Durmaz, Olkar Abdulmajed, Rıza Durmaz
doi: 10.5222/MMJ.2020.98048  Pages 253 - 260
Coronaviridae familyası içerisinde sınıflandırılan koronavirüsler (CoVs) oldukça geniş bir omurgalı grubu enfekte etmektedir. İnsanlarda hastalık oluşturan yedi tip koronavirüsten HCoV-229E ve NL63 alfa, MERS-CoV, SARS-CoV, HCoV-OC43, HCoV-HKU1, SARS-CoV-2 ise beta cinsinde yer almaktadır. SARS-CoV-2, yeni bir koronavirüs hastalığına (Coronavirus disease 2019; COVID-19) yol açan zarflı, pozitif-polariteli, tek sarmallı bir RNA virüsüdür. SARS-CoV-2’nin mutasyon kabiliyeti viral evrimi ve genom değişkenliğini yönlendirir. Böylece virüslerin konakçı bağışıklığından kaçmasına ve ilaç direnci geliştirmesine olanak tanır. Ayrıca viral mutasyonların izlenmesi yeni aşılar, anti-viral ilaçlar ve tanı sistemlerinin geliştirilmesi için de önemlidir. Konak hücrede replikasyon esnasında virüste mutasyon oluşmakta ve bu mutasyonlar yeni soylara aktarılmaktadır. Bu nedenle SARS-CoV-2 genomundaki mutasyonların sistematik bir biçimde izlenmesi virüsün ulusal ve uluslararası moleküler epidemiyolojisinin gözlenmesine olanak sağlamaktadır. SARS-CoV-2’nin spike (S) proteini virüsün konak hücre reseptörü olan anjiyotensin dönüştürücü enzim 2’ye (ACE2) bağlanması, membrana füzyonu, aşı çalışmaları ve oluşacak bağışık yanıtta hayati öneme sahiptir. Bu nedenle S glikoproteinini kodlayan gendeki mutasyonlar ve özellikle virüsün ACE-2 reseptörüne bağlanma bölgesindeki (RBD olası varyasyonların irdelenmesi, üzerinde durulması gereken önemli konulardandır. Bu yazıda SARS-CoV-2 S glikoproteininde saptanmış olan mutasyonlar ve olası etkileri hakkında bilgi sunulmuştur.
Coronaviruses (CoVs) classified in the Coronaviridae family infect a very large spectrum of vertebrate group. Seven CoVs that cause human disease consist of Alpha-CoVs, which are HCoV-229E, and NL63 and beta-CoVs, which are MERS-CoV, SARS-CoV, HCoV-OC43, HCoV-HKU1, and SARS-CoV-2. SARS-CoV-2 is an enveloped, positive-polarity, single-stranded RNA virus responsible for a new Coronavirus disease 2019 (COVID-19). The mutagenic ability of the SARS-CoV-2 directs its evolution and genome variability, thus allowing viruses to escape from host immunity and develop drug resistance. Tracing viral mutations is also important for the development of new vaccines, antiviral drugs, and diagnostic systems. During replication in the host cell, genomic mutations occur in the virus and these mutations are transferred to new generations. For this reason, systematic monitoring of mutations in the SARS-CoV-2 genome allows observation of the national and international molecular epidemiology of the virus. SARS-CoV-2 spike (S) glycoprotein is vital in the binding of the virus to the host cell receptor that is angiotensin converting-enzyme 2 (ACE2), membrane fusion, vaccine studies and immune response to the virus. Therefore, mutations in the gene encoding the S glycoprotein and especially the possible variations in the receptor binding domain (RBD) in S gene are important issues to be emphasized. In this article, information about the mutations observed in the SARS-CoV-2 S glycoprotein and their possible effects are presented.

CASE REPORTS
15.Epiphrenic Diverticulum in an Infant with Congenital Esophageal Stenosis Associated with Esophageal Atresia
Çiğdem Ulukaya Durakbaşa, Gursu Kiyan, Sinem Aydöner, Ahmet Pirim, Hatice Seneldir, Sercin Özkök, Ismail Caymaz
doi: 10.5222/MMJ.2020.22220  Pages 261 - 265
Doğumsal özofagus darlığı (DED) tek başına görülen veya özofagus atrezisine (ÖA) eşlik eden nadir bir doğumsal hastalıktır. DED özofagus boşalmasında tıkanıklık ile seyreder. Özofagusun epifirenik divertikülleri (ED) ise diyafram üstü seviyede oluşan özofagus çıkıntılarıdır. Altta yatan özofagus motor hastalıkları zemininde gelişirler. ÖA ameliyatı sonrasına rutin takip sırasında DED tanısı konan bir hasta sunulmuştur. Hastaya DED tedavisi amacıyla çeşitli kereler balon dilatasyon uygulanmış ve semptomlarında kısmi düzelme sağlanmıştır. Bu tedavi esnasında yapılan ileri tetkiklerle hastada ED geliştiği tespit edilmiştir. Cerrahi rezeksiyon ile başarılı sonuç elde edilmiştir. DED nedeniyle gelişen ED daha önce bildirilmemiştir. Bu iki nadir duruma ilişkin uygulanan tanısal yöntemler, tedavi seçenekleri ve klinik izlem bulguları vurgulanmıştır.
Congenital esophageal stenosis (CES) is a rare congenital disorder which may be isolated or associated with esophageal atresia (EA). It courses with esophageal outflow tract obstruction. Esophageal epiphrenic diverticulae are esophageal outpouchings above diaphragm which develop because of an underlying esophageal motor disorder. We present an infant who had CES associated with EA detected during the course of routine follow-up. She underwent several sessions of esophageal balloon dilatations for CES with some symptomatic improvement. However, an epiphrenic diverticulum (ED) developed during the course of treatment which was detected by further investigations. A surgical excision was performed with a successful outcome. An ED developed secondary to CES has not been previously reported. We have highlighted the diagnostic modalities employed, treatment options, and clinical follow-up for these two rare conditions in children.

16.Atypical Presentation of Takotsubo Cardiomyopathy: Stroke as a Predisposing Factor
Wah Loong Chan, Mohd Al-Baqlish Mohd Firdaus, Mohd Ridzuan Mohd Said, Imran Zainal Abidin
doi: 10.5222/MMJ.2020.47374  Pages 266 - 270
Takotsubo syndrome is a rare disease and remained ambiguous with its etiology. The disease manifests in various clinical characteristics and even mimicking acute coronary syndrome. We are reporting a case of an elderly lady who manifested by unsteady gaits and recurrent falls. Subacute infarct of the right corona radiata was observed on the brain CT. In addition, coronary angiography and ventriculogram were performed because of dynamic ECG changes and elevated troponin I levels. The angiogram was normal while ventriculogram showed apical ballooning. She was diagnosed and treated as Takotsubo syndrome.

17.Extracardiac Rhabdomyoma Mimicking Plunging Ranula
Ikram Hakim, Mohd Razif Mohamad Yunus
doi: 10.5222/MMJ.2020.88120  Pages 271 - 275
Adult type of extracardiac rhabdomyoma is a benign tumour of mature striated muscle histopathologically. It is a slow growing tumour with predilection to occur in head and neck region. It appeared mainly to be a solitary lesion with 15% can occurred multicentric. A 56 year-old gentleman presented to us with floor of mouth swelling for 1 year and right neck swelling for 3 years mimicking a plunging ranula. Radiological imaging revealed enhancing mass at the floor of mouth and submandibular region. The mass represent a non vascular benign tumour. Subsequently, the patient underwent combine approached excision of the mass via transcervical and transoral method. Histopathological examination revealed adult type of extracardiac rhabomyoma. Adult type of extracardiac rhabdomyoma should be considered in the differential diagnosis in the head and neck masses. A complete excision will reduce the risk of recurrence.

18.Nodular Fasciitis of the Posterior Ethmoid Sinus: Uncommon Tumour at Uncommon Sites
Addina Mohd Baki, Rosdi Ramli, Rosli Mohd Noor, Irfan Mohamad, Murni Jais
doi: 10.5222/MMJ.2020.90093  Pages 276 - 280
Nodular fasciitis (NF) is an uncommon and benign tumour-like fibroblastic proliferation that is difficult to distinguish from sarcoma both clinically and histologically. In addition, it is a type of lesion characterised by having a potential for spontaneous regression. NF is frequently misdiagnosed due to its rapid growth, rich cellularity, and mitotic figure. Although NF is only rarely diagnosed in children, the head and neck represent the most common locations for NF among this population. The cause of NF remains unknown, however trauma is believed to be an important triggering factor. We describe an unusual case of NF in the posterior ethmoid sinus in a six-year-old boy with no history of trauma. The NF was incidentally noted on a computed tomography scan after the patient complained of a squint. The diagnosis of NF was also supported by histopathology and specific immunohistological staining. A surgical biopsy was performed, and no recurrence was observed after one year.




 

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