Atilla Halil Elhan

Adaptation of the Functional Independence Measure for use in Turkey

Objective: To adapt the Functional Independence Measure (FIM) for use in Turkey and to assess its validity and reliability. Design: After the translation procedure, reliability was assessed using internal consistency, inter-rater reliability (kappa) and the intraclass correlation coefficient (ICC). Construct validity was tested by association with impairments and by fit of data to the Rasch model. Setting: The study was undertaken in an inpatient rehabilitation unit of the Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Ankara. Subjects: Consecutive stroke (n = 51) and spinal cord injury (SCI) (n = 62) patients admitted for rehabilitation over a period of three years were assessed at admission and discharge. Results: Internal consistency was good for stroke, and for SCI. The level of agreement between two raters was sufficient with kappa levels of above 0.48 for SCI and above 0.44 for stroke. Minimum ICC found was 0.90. Construct validity showed expected associations with the impairment scales. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality in the motor scale. Conclusion: Adaptation of the FIM has been successful and it can be used in Turkey as long as the limitations are recognized.

Hepatic Steatosis: Quantification by Proton Density Fat Fraction with MR Imaging versus Liver Biopsy

PURPOSE To determine utility of proton density fat fraction (PDFF) measurements for quantifying the liver fat content in patients with nonalcoholic fatty liver disease (NAFLD), and compare these results with liver biopsy findings. MATERIALS AND METHODS This retrospective study was approved by the institutional review board with waivers of informed consent. Between June 2010 and April 2011, 86 patients received a diagnosis of NAFLD. Ten patients did not accept liver biopsy and six patients had contraindications for magnetic resonance (MR) imaging. Seventy patients were included in this study. Seventy patients with NAFLD (40 men, 30 women; mean age, 44.7 years; range, 16-69 years) underwent T1-independent volumetric multiecho gradient-echo imaging with T2* correction and spectral fat modeling. Median time interval between MR imaging and liver biopsy was 14.5 days (range, 0-259 days). MR examinations were performed with a 1.5-T MR imaging system. Complex-based PDFF measurements were performed by placing regions of interest in Couinaud system segments V-VI and all liver segments from I to VIII. All liver biopsy specimens were retrieved from archives and evaluated by one pathologist for hepatic steatosis according to criteria from a previous study. Pearson correlation coefficient, receiver operating characteristics, and linear regression analyses were used for statistical analyses. RESULTS Mean PDFF calculated with MR imaging was 18.1% ± 9.5 (standard deviation). Close correlation for quantification of hepatic steatosis was observed between PDFF and liver biopsy (r = 0.82). PDFF was effective in discriminating moderate or severe hepatic steatosis from mild or no hepatic steatosis, with area under the curve of 0.95. The correlation between biopsy and PDFF-determined steatosis was less pronounced when fibrosis was present (r = 0.60) than when fibrosis was absent (r = 0.86; P = .02). CONCLUSION PDFF measurement by MR imaging provided a noninvasive, accurate estimation of the presence and grading of hepatic steatosis in patients with NAFLD. Hepatic fibrosis reduced the correlation between biopsy results and PDFF.

Validation of the Turkish version of the Roland-Morris disability questionnaire for use in low back pain

Study Design. A reliability and validity study of a previously translated version of the Roland-Morris Disability Questionnaire (RMDQ). Objectives. To validate the Turkish version of the RMDQ for use in low back pain. Summary of Background Data. Clinical and epidemiologic research related to low back pain in the Turkish population would be facilitated by the availability of well-established outcome measures. Methods. A total of 81 outpatients with low back pain, 64 of whom were followed up on a second occasion, were assessed by the RMDQ. Reliability was assessed using internal consistency and the intraclass correlation coefficient. Internal construct validity was assessed by Rasch analysis; external construct validity was assessed by association with pain and spinal movement. Responsiveness was tested by both the nonparametric and parametric effect sizes. Results. Internal consistency of the RMDQ is found to be adequate (>0.85) at both times, with high intraclass correlation coefficient also at both time points. Internal construct validity of the scale is good, indicating a single underlying construct. Expected associations with pain confirm external construct validity. There is little evidence of differential item functioning. The scale is at the ordinal level. Responsiveness of the RMDQ is good and greater than observed change in spinal movement. Conclusions. The RMDQ is a robust unidimensional ordinal measure, largely free of differential item functioning, which works well in the Turkish population. Nonparametric effect sizes of ordinal scales are found to overestimate or underestimate the true effect size depending on the nature of the scale and the distribution of patients at baseline.

Effect of sphincter-sacrificing surgery for rectal carcinoma on quality of life in Muslim patients.

AbstractPURPOSE: Living with a permanent colostomy significantly diminishes a patient’s quality of life. However, little is known about its influence on worship patterns in Muslims. Therefore, the aim of this study was to assess the quality of life in Muslim patients after surgery for rectal carcinoma, especially with respect to religious worship. METHODS: We studied 178 patients who had undergone curative surgery for colorectal carcinoma. The patients fell into three groups based on the type of surgery they underwent: abdominoperineal resection (n = 75), sphincter-saving resection (n = 51), and anterior resection including sigmoid colectomy (n = 52). Quality of life was measured with the Medical Outcomes Study Short Form 36 Health Survey and a questionnaire that asked participants about their work responsibilities, sexual life, and religious worship. RESULTS: The scores for all eight subscales of the Short Form 36 in the abdominoperineal resection group were significantly poorer than those in the sphincter-saving resection and anterior resection groups (P < 0.001). In addition, social life and work responsibilities were significantly more affected in the abdominoperineal resection group than in the other two groups (P < 0.001). A significantly (P < 0.001) greater number of patients in the abdominoperineal resection group stopped praying daily (either alone or in a mosque) and fasting during Ramadan. CONCLUSION: Two aspects of religious worship (praying and fasting) were significantly impaired in the Muslim patients who had a stoma as a result of sphincter-sacrificing surgery. To improve quality of life in these patients, religious issues as they relate to the presence of a stoma should be discussed during preoperative counseling, the informed consent process, and counseling with local religious authorities.

Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity.

PURPOSE: Dysfunction of pelvic floor may cause many different symptoms, such as urinary and anal incontinence, obstructed defecation and constipation. No previous studies have examined all of these symptoms together. The purposes of the present study were to determine prevalence of pelvic floor disorders among the female population and to evaluate the impact of age, parity, and mode of delivery on these disorders. METHODS: The study was performed on a general population of Turkish women. Women were excluded who were pregnant, who were within 6 months postpartum, who had cognitive disorders or neurological diseases, and who had a history of previous gastrointestinal, anorectal, or gynecological surgery. A questionnaire about urinary incontinence, anal incontinence, constipation, and obstructed defecation along with an extensive obstetric history was administered to 4002 women in face-to-face interviews. All symptoms were defined according to the standard terminology. RESULTS: The median age of the participants was 41 years (range, 15–86). Of the women interviewed, 1067 had no deliveries, 434 women delivered by cesarean only, and 2501 women had one or more vaginal deliveries. Five hundred thirty women had delivered one child, 1880 women had delivered 2 to 3 children, and 582 women had delivered ≥4 children. Overall, 67.5% of women experienced pelvic floor dysfunction of at least one major type. The prevalence of each pelvic floor disorder evaluated in this study was as follows: anal incontinence, 19.8%; urinary incontinence, 50.7%; constipation, 33.2%; and obstructed defecation, 26.8%. Analysis of risk factors demonstrated that age was the major factor associated with the development of pelvic floor dysfunction. Vaginal delivery and higher parity increased the risk of both urinary and defecatory symptoms of pelvic floor dysfunction. CONCLUSION: The study data demonstrate that pelvic floor dysfunction is a common problem among women and it is strongly linked to childbirth and aging.

Morphology of corneal nerves and corneal sensation in dry eye: a preliminary study

PurposeTo evaluate the corneal sensitivity and nerve morphology in dry eyes.MethodsA total of 32 eyes of 16 patients (10 Sjogrens syndrome and six non-Sjogrens syndrome) and 19 eyes of 10 age-matched controls were studied. Sensitivity of the central cornea was measured by the Cochet–Bonnet aesthesiometer. The morphology of corneal nerves was studied by in vivo confocal microscopy (ConfoScan 2.0, Fortune Technologies Srl, Vigonza (PD), Italy). Sub-basal epithelial nerve plexus, subepithelial nerve plexus, and stromal nerves were localized and evaluated for the number of nerves, thickness, reflectivity, and tortuosity for each frame.ResultsThe mean corneal sensitivity of dry eye patients (5.6 mm/grs/S) was found significantly lower than that of the control (5.0 mm/grs/S) group (P<0.01). Although the subepithelial nerves were thicker in dry eyes (mean: 6.38±1.18 μm) than control eyes (mean: 5.72±1.27 μm), this difference was not significant (P>0.05).ConclusionDecreased corneal sensitivity is not associated with morphological changes of corneal nerves in dry eyes.

An Assessment of Fertility in Boron-exposed Turkish Subpopulations

In order to assess the effects of boron and its compounds on human health in a country with the worlds largest deposits, investigations were carried out on fertility and reproduction in the most highly exposed populations. The 927 probands, 697 male and 230 female, interviewed in the field were selected from six different areas of Turkey, in the provinces of Balikesir, Eskisehir, and Kutahya, with the highest boron deposits. These people are exposed to boron environmentally or occupationally or both. The drinking waters of high-boron soils contain 0.7-29 mg B/L compared with 0.05-0.45 mg B/L of low-boron soils. By the so-called pedigree technique 5,934 marriages were ascertained over three generations from all study areas. Childless families among 911 probands were 29 in number and 3.17% in frequency with minor variations from one area to the next, and 3.0% averaged over the generations. Infertility rates in a boron-free community near Ankara with 625 families studied over three generations was 4.48%, and in a larger population of 49,856 families randomly investigated by us throughout the country was 3.84%. No significant differences were observed in terms of marital status and childbearing between 222 and 399 occupationally boron-unrelated and boron-related men, respectively. Nor was there any difference with respect to other aspects studied. It was concluded that, within the limitations of this study, there was no evidence that boron interferes with human fertility and reproduction.

Clinical and histopathological evaluation of sucralfate in prevention of oral mucositis induced by radiation therapy in patients with head and neck malignancies

Forty-four patients with head and neck malignancies were included in a prospective, randomized, double-blind, placebo-controlled study for evaluation of sucralfate in prevention of oral mucositis induced by radiation therapy. Patients were randomized to receive oral suspensions of either sucralfate (n = 23) or placebo (n = 21) in six daily doses of 1 g. The primary tumors were treated with portals covering at least one-third of the oral mucosa to a minimum dose of 60 Gy. Drug therapy was not associated with significant adverse effects and compliance was satisfactory. Daily inspection of the oral mucosa and questionnaires for oral mucositis-related items demonstrated reduction in oral mucositis scores and oral pain scores and biopsies obtained from the buccal mucosa demonstrated reduction in evidence of altered vascular calibration, altered vascular permeability and leukocyte emigration with sucralfate. Clinical and histopathological demonstration of reduction in oral mucositis with sucralfate suggests that sucralfate might be recommended in the prevention of oral mucositis induced by radiation therapy in patients with head and neck malignancies.

Bone marrow microvessel density (MVD) in adult acute myeloid leukemia (AML): therapy induced changes and effects on survival.

Based on the strong evidence in favor of an increase in microvessel density (MVD) in hematological malignancies, we evaluated VEGF immunoreactivity and MVD measurement in bone marrow biopsies of 36 AML patients at diagnosis and following therapy. MVD assessment was based on CD31, CD34 expressing vessels. The values were calculated for only one marker if the other vascular marker was positive on blasts, otherwise both markers were used. VEGF immunoreactivity was also scored. Comparison of MVD values of 36 AML patients with 18 non-malignant controls showed a significantly higher MVD in AML (CD31: P = 0.004, CD34: P < 0.001), which is independent of other variables such as cellularity or blast percentage. Following induction chemotherapy, the responders showed a significant decrease in blast counts (P < 0.001), cellularity (P = 0.001) and MVD (P = 0.050) quantification with CD31. Higher baseline MVD (CD34) values were associated with shorter overall survival (P = 0.0027). These results are encouraging for inclusion of MVD enumeration in bone marrow examinations of AML patients at diagnosis as an additional prognostic factor.

Comparison of long-term quality of life after laparoscopic and open cholecystectomy

Background: Although many studies have compared open and laparoscopic procedures, showing many advantages in favor of the laparoscopic technique during the early postoperative period, only a limited number of reports in the literature compare the two techniques during the later follow-up period with regard to quality of life. This study aimed to compare the effects of these two cholecystectomy techniques on the quality of life and clinical outcome of the patients during long-term follow-up evaluation. Methods: This study evaluated 200 patients who underwent cholecystectomy operations with either technique between 1993 and 1999 in our department. There were 100 patients in each group. Both groups were similar with respect to age, gender, body mass indexes, American Society of Anesthesiology (ASA) scores, and indications for surgery. The Medical Outcome Study Short Form 36 Health survey (SF-36), which includes 36 items, was used for evaluating the quality-of-life index. In addition to this, a system-specific instrument for gastrointestinal diseases was used to investigate clinical outcome. Results: The mean administration time for the questionnaire was 46.8 ± 18.7 months in the laparoscopic cholecystectomy (LC) group and 41.5 ± 16 months in the open cholecystectomy (OC) group. Statistically significant differences were noted in the scores for all eight SF = 36 health status domains in favor of laparospopic surgery. No statistically significant difference was found for abdominal pain, location of the pain, referral to a doctor for the pain, accompanying symptoms, relieving factors for the pain, distention, and dyspeptic complaints, usage of antacid therapy, weight changes, changes in bowel habit, need for a special diet, or sexual functions between the two groups. Conclusions: The gastrointestinal clinical symptoms were similar in the two groups during the long-term follow-up evaluation, but laparoscopic cholecystectomy was found to be significantly superior to the open technique with respect to the quality of life over the long term.