Τετάρτη, 15 Μαΐου 2019

Clinical Practice

Maternal and perinatal outcomes after caesarean delivery in early and late onset preeclampsia with HIV positive and HIV negative South African Women
OA Onyangunga, TA Naicker, J Moodley

Nigerian Journal of Clinical Practice 2019 22(5):591-597

Objective: We analyzed the maternal and perinatal outcomes in early onset preeclampsia (EOPE) and late onset preeclampsia (LOPE) pregnant women who had scheduled caesarean deliveries. We sub-analyzed the two categories into HIV positive and HIV negative. Patients and Methods: This prospective study was conducted at a regional hospital in Durban, South Africa during 14 months. A total of 14304 deliveries were registered. Out of the 1759 preeclampsia, 351 (19.9%) were EOPE and 1408 (80.1%) were LOPE. Hundred and twenty preeclamptics (n = 120) scheduled for caesarean delivery were selected and divided into two categories namely EOPE (n = 60) and LOPE (n = 60). Each preeclampsia category was then further stratified into HIV positive (n = 30) and HIV negative (n = 30) groups. Maternal demographic, clinical details for preeclampsia, blood laboratory tests, maternal, and perinatal outcomes were recorded. Results: Women with EOPE were older compared to those with LOPE (P = 0.0001). Also the HIV positive women were older compared to the HIV negative groups in both EOPE and LOPE categories (P = 0.03). However, multiparous and primiparous were predominant in EOPE and LOPE categories, respectively (P = 0.00 and P = 0.00). The severity of hypertension and the HIV status did not differentiate the 2 groups. Overall, maternal complications (eclampsia, persistent postpartum hypertension, HELLP syndrome, maternal death) and poor fetal outcomes occurred predominately in EOPE. Conclusion: This study confirms the heterogeneity of preeclampsia and shows that the timing of onset of this pregnancy disorder is important to disease severity. Further HIV status influences maternal and neonatal outcome. 


Which one predicts mortality better? Hemogram and ST elevation myocardial infarction
A Avci, BS Avci, Y Donmez, M Kocer, M Gulen, AI Ozer, A Bulut, M Koc, H Nazik, S Satar

Nigerian Journal of Clinical Practice 2019 22(5):598-602

Objective: The aim of this study was to determine the effectiveness of hematological parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values. Subjects and Methods: The study began with approval of the ethics committee. In total, 1,929 patients over 18 years of age, whose date could be obtained, were included in the study. From the hemogram parameters, white blood cells (WBC), red cell distribution width, mean platelet volume, and ratio of neutrophils to lymphocytes (NLR) values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. For statistical analysis, “SPSS for Windows Version 21” package program was used. Findings: About 71.7% (n = 1384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1785) were discharged from the hospital, whereas the remaining 144 patients (7.5%) were exitus in the hospital. When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by receiver operating charecteristics analysis, NLR was found to be the strongest predictor (area under the curve [AUC], 0.772, standard deviation [SD] = 0.022, 95% confidence interval [CI]). It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI). Conclusion: The use of predictors for the prediction of mortality for ST elevation myocardial infarction patients is of great importance for faster implementation of treatment modalities. We found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors. 


Anatomic variations associated with antrochoanal polyps
M Gursoy, N Erdogan, YK Cetinoglu, F Dag, E Eren, ME Uluc

Nigerian Journal of Clinical Practice 2019 22(5):603-608

Objective: Although more than a century has passed since antrochoanal polyps (ACPs) were first defined, etiopathogenesis still remains unclear. The aim of this study was to investigate the relationship between ACPs and sinonasal cavity variations. Subjects and Methods: One hundred and forty-four patients with ACP on paranasal sinus computed tomography scans (ACP group) and 160 paranasal sinuses without ACP (control group) were included into the study. The study group was evaluated in respect of the presence of retention cyst in the contralateral maxillary sinus and sinus bone wall sclerosis thickening. Both groups were also compared with respect to the frequency of sinonasal anatomic variations, nasal septal deviation, variations of the uncinate process insertion, concha bullosa, paradoxical middle turbinate, and accessory maxillary sinus ostium. In the ACP group, the cases with septal deviation (SD) were also evaluated whether the deviation convexity was towards the polyp side or the opposite side. In addition, the posterior extension of ACPs were evaluated in three groups as middle meatus, nasopharynx, and oropharynx extension. Results: The prevalence of retention cyst, sinus wall sclerosis thickening, SD, and accessory maxillary ostium was significantly higher in the ACP group. A negative directional correlation was determined between the SD side and ACP side. When the ACP extensions were examined, middle meatus extension was seen in 32.6%, nasopharynx in 56.3%, and oropharynx in 11.1%. Conclusion: Accessory ostium may be an accelerating factor in the transformation of retention cyst to ACP. Furthermore, the changes in the nasal passage airflow on the opposite side suggest that SD contributes to this process. 


A comparison of intravenous sugammadex and neostigmine + atropine reversal on time to consciousness during wake-up tests in spinal surgery
E Biricik, V Alic, F Karacaer, M Celiktas, H Unlugenc

Nigerian Journal of Clinical Practice 2019 22(5):609-615

Objective: The effect of sugammadex on consciousness is not yet fully understood. This prospective, randomized, double-blind, multicenter study was performed to compare the effects of intravenous (IV) sugammadex and neostigmine + atropine reversals on time-to-consciousness during intraoperative wake-up tests in patients undergoing spinal surgery. Subjects and Methods: A total of 66 American Society of Anesthesiologists I–II patients aged 10–25 years undergoing spinal surgery were recruited. In all patients, bispectral index (BIS), motor-evoked potential (MEP), somatosensory-evoked potentials (SSEP), and train-of-four (TOF) scores were monitored. Patients received the same total IV anesthesia protocol with a propofol–remifentanil mixture. Patients were randomly allocated into two groups. During wake-up test, when the TOF count reached 2 (T2), either sugammadex 2 mg.kg−1 in group S or neostigmine 0.04 mg.kg−1 + atropine 0.01 mg.kg−1 in group N were administered. BIS90, SSEP90, MEP90 was recorded when TOF ratio reached 90, whereas time-to-consciousness (Timecons) was recorded when the patient responded to verbal commands. Results: BIS90 (77.4 ± 4.7, 74.8 ± 3.7), SSEP90(36 ± 9.9, 29.7 ± 8.5), and MEP90 (465.3 ± 34.8, 431.3 ± 28.2) values were significantly greater in group S than in group N (P < 0.05 for each variables). Timecons was significantly shorter with sugammadex than with the neostigmine + atropine combination (P < 0.05). Conclusion: Using IV sugammadex 2 mg.kg−1 reversal provides faster responses to verbal commands than neostigmine–atropine combination during the intraoperative wake-up test in patients undergoing spinal surgery because the time to consciousness was significantly shorter. This difference was thought to be related with faster return of neuromuscular transmission because the TOF ratio was >0.9 well before return of consciousness in both groups. 


3-D mapping of cortical bone thickness in subjects with different face form and arch form: A CBCT analysis
S Chaturvedi, MA Alfarsi

Nigerian Journal of Clinical Practice 2019 22(5):616-625

Objective: To determine the relationship between face form (FF), arch form (AF), and cortical bone thickness in anterior and posterior region of the mandibular jaws, using cone beam computed tomography (CBCT). Patients and Methods: Total 90 subjects were selected. For each subject FF (euryprosopic, mesoprosopic, and leptoprosopic) was determined using Prosopic Index. CBCT scans were done for each subject to determine mandibular AF (as tapered, oval, or square in horizontal sections) and cortical bone thickness (at two vertical levels 4 and 7 mm from the alveolar crest in the anterior and posterior region of mandible in sagittal sections). Numerical data so obtained were analyzed using descriptive statistics, analysis of variance followed by Tukey HSD (honestly significant difference) test at a statistical significance level of 5%. Results: Significant difference in thickness of cortical bone was noted between various AF and face. In square AF, mean value of thickness of cortical bone was highest both at 4 and 7 mm vertical level and tapered AF had minimum mean values at 4 mm and oval at 7 mm in anterior region and posterior region on buccal and lingual sides, in all the three-FF. Conclusion: Significant effects of FF and AF on cortical bone thickness were seen both on buccal and lingual side and the effect of AF was more compared to FF. The availability of the cortical bone in euryprosopic FF and square AF patients was more; therefore, implants with a shorter length may be used in these clinical cases. 


Rational drug use and prescribing behavior of family physicians in Erzurum, Turkey
EO Calikoglu, E Koycegiz, Z Kosan, A Aras

Nigerian Journal of Clinical Practice 2019 22(5):626-632

Background: Widespread irrational medical prescription adversely affects the outcomes of patient health and medical services. Aim: This study aims to investigate the determinants of medical prescription behavior of family physicians in Erzurum Province. Materials and Methods: This cross-sectional descriptive study was conducted during August–December 2016 on a voluntary sample of 191 out of 234 physicians (81.6%) working at family health centers in the districts of Erzurum. Physicians were visited at their workplaces, and data were collected using a self-administered and structured, 45-item questionnaire. Results: The mean age of the physicians was 34.7 ± 7.9 years, and 70.7% (n = 135) of the participants were males. About 83.8% (n = 160) of physicians responded “yes” or “sometimes” to the question “Do you prescribe medicine on demand of the patients?” The two most important factors that affected the prescribing behavior of the participants were the pharmacology lectures attended during medical education (50.8%) and the prescribing experience acquired during clinical internship (46.0%). Presentations given by the representatives of drug companies, in-service training programs after graduation, and Internet/mobile phone applications had the lowest rate of contribution as behavioral determinants. The participants perceived having sufficient information in the areas of indication for use (77.5%) and daily dose (72.8%). Only 4.2% of participants deemed their knowledge of medication costs sufficient. Pharmacology lessons were found to be more effective in the prescribing behaviors of the physicians who had less than 10 years of professional experience (Chi-square = 12.131; P = 0.002). Conclusion: Rational medical prescription continues to be a trouble among family physicians. The study findings suggest a substantial knowledge gap in participating physicians occurring after graduation and clinical internship training, in the areas of costs of medicine and rational medical prescribing. 


Comparative evaluation of marginal adaptation and microleakage of low-shrinking composites after thermocycling and mechanical loading
OK Hepdeniz, RB Ermis

Nigerian Journal of Clinical Practice 2019 22(5):633-641

Aims: The aim of this study was to evaluate and correlate marginal adaptation and microleakage of different low-shrinking composites. Materials and Methods: Standardized class V cavities (n = 20/group) with occlusal margin in enamel and gingival margin in dentin were restored with low-shrinking silorane-based (Filtek Silorane) or methacrylate-based (Clearfil Majesty Posterior, Grandio, Reflexions XLS, Tetric EvoCeram, Premise, Ceram-X Duo, Aelite LS Posterior) composites and a conventional composite (Filtek Z250). All teeth were stored in water (24 h), thermocycled (5000×), and mechanically loaded (60,000×). Marginal adaptation of epoxy resin replicas was analyzed using scanning electron microscope. Microleakage of the restoration was assessed by dye penetration on sectioned specimens under stereomicroscopy. Data were statistically analyzed with Mann–Whitney U test, with a significance of P < 0.05. Pearson's correlation test was used to evaluate the correlation between results of margin analysis and microleakage. Results: No statistical difference in marginal gap formation was determined between Filtek Silorane and Z250. The lowest microleakage score at dentin margins was recorded for Filtek Silorane, which was not significantly different from that of all other groups. No similar ranking between the results of microleakage at enamel and dentin margins was observed for the materials tested. Marginal adaptation was not correlated to microleakage, except for Filtek Silorane, Grandio, and Filtek Z250. Conclusions: Compared to the conventional composite Filtek Z250, Filtek Silorane demonstrated no improvements with reduced marginal gap formation. Low-shrinking properties of composites appear to have no ability of sealing restoration margins and preventing leakage. 


Comparison of clinical findings in adult and paediatric burn victims
C Tiryaki, MC Haksal

Nigerian Journal of Clinical Practice 2019 22(5):642-647

Aim: We aimed to compare the epidemiological data, general characteristics, laboratory findings, and outcomes of burn patients with ≤18 and >18 years of age. By this way, we also aimed to determine the effective preventive measures appropriate for different age groups. Subjects and Methods: The data of 630 consecutive patients admitted to our hospital with 2nd or 3rd degree burn injuries were retrospectively investigated. The patients were grouped into two regarding their ages as ≤18 (group 1) and >18 (group 2) years. Data of age, gender, cause of injury, location of injury, total burn area, length of hospital stay, laboratory data, and outcome of treatment were recorded. Results: We determined that although burn injury is more common in males compared with the females, male predominance is more commonly determined in older age group than children. Extremities are most commonly affected areas in both groups. In children, the most common etiological agent was hot beverages while in older age group electrical burns, and work accidents were more common (P < 0.001). Among children, patients younger than 3 years of age were compromising 62.4% of all cases. In adult group, total burned body surface area %, operation or intensive care unit requirement, hospitalization period, blood transfusion, or fresh frozen plasma requirement and the number of patients expired were all significantly higher compared with the children. Regarding the admission laboratory data, renal and liver function tests were significantly worse in older age group. However, neutrophile percentage was significantly higher in older group which may be a sign of augmented inflammatory response. Conclusion: Especially clinicians and public health providers should be aware of the clinical findings and outcomes of burn victims in order to drive more effective preventive measures. 


Factors impacting 1-year mortality after hip fractures in elderly patients: A retrospective clinical study
M Gurger

Nigerian Journal of Clinical Practice 2019 22(5):648-651

Background: This study aimed to evaluate risk factors that impact 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. Patients and Methods: Overall, 109 patients aged ≥65 years with nonpathological hip fractures, treated between 2015 and 2016, were included in this study. Thirty-nine patients (35.8%) were treated with primary arthroplasty, and 70 patients (64.2%) were treated with proximal femoral nail. To determine whether the risk factors affected mortality, Kaplan–Meier and log-rank analyses were conducted, and a Cox regression analysis was conducted to include the factors determined to have an impact on mortality. Results: Twelve patients (11%) died during hospitalization, and 24 patients (22%) died within 1 year after discharge from the hospital. The mortality risk was high for patients who underwent surgery 72 h after fracture, who could not independently perform their daily activities before the operation, had accompanying diseases, had an American Society of Anaesthesiologists score of 3 or 4, and had postoperative complications. There was no statistically significant difference between primary arthroplasty group and proximal femoral nail group with respect to mortality risk. Conclusion: Delayed surgery and postoperative complications may be the most important risk factors increasing 1-year mortality in elderly patients with hip fractures after treatment with primary arthroplasty and proximal femoral nail. These two risk factors can be prevented with proper precautions, and the rate of 1-year survival for these patients can be increased. 


Analyses of clinical and osteoimmunological parameters on keratinized mucosa around dental implants
E Sukuroglu, E Baltacioglu

Nigerian Journal of Clinical Practice 2019 22(5):652-660

Introduction: This study investigated the effects of keratinized mucosa width (KMW) on peri-implant tissues by evaluating peri-implant clinical and bone resorption parameters. Subjects and Methods: Seventy-one dental implants (DIs) were separated based on adequacy/inadequacy of KMW. DIs with inadequacy KMW were grouped as peri-implant plastic surgery (PIPS) (free gingival graft/free periosteal graft groups) and maintenance (M) groups. DIs with adequacy KMW were grouped as the controls. Peri-implant clinical parameters were measured at the baseline and 6th month. Levels of receptor activator of nuclear factor κB ligand (RANKL) and osteoprotegerin (OPG) in peri-implant sulcular fluid were determined after clinical measurements using enzyme-linked immunosorbent assay. Results: In baseline, gingival index, bleeding on probing, and plaque index (PI) were lower in controls compared to the PIPS and M groups, and KMW was higher. At 6th month, peri-implant pocket depth and PI were lower in the PIPS groups and controls compared to the M group, and KMW was higher. While RANKL and OPG values and RANKL/OPG ratio at baseline were not significantly different between groups, OPG concentration and RANKL/OPG ratio in the 6th month were higher in the PIPS group compared to the M group (P < 0.05). The RANKL/OPG ratio decreased at 6th month in the PIPS groups and controls (P < 0.05). Positive and negative correlations were observed between peri-implant clinical and osteoimmunological parameters. Conclusion: This study demonstrated that adequate KMW and PIPS techniques exhibited positive effects on clinical peri-implant parameters and osteoimmunological mediators. 


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