Ismail Mihmanli

Cephalic Vein and Hemodialysis Fistula Surgeon's Observation Versus Color Doppler Ultrasonographic Findings

The aim of this study was to evaluate whether preoperative color Doppler ultrasonography improves immediate success rates of arteriovenous fistulas for dialysis. One hundred twenty‐four patients with chronic renal failure underwent color Doppler ultrasonographic examination of both arms, including the cephalic vein, before arteriovenous fistula construction. Patients were randomly divided into 2 groups: A and B. In group A, there were 52 patients, and the surgeon planned to construct arteriovenous fistulas depending only on physical examination. In group B, which comprised 72 patients, surgeons performed arteriovenous fistula construction on sites labeled by color Doppler ultrasonography. In group A, of 52 patients who had surgery for arteriovenous fistula construction, 13 had fistulas that did not function. Among these 13 patients, 8 were found to have chronic thrombotic changes in the cephalic vein on color Doppler ultrasonography, and 5 had none of these changes. When we checked the color Doppler ultrasonographic findings, we noted that these 5 patients had decreased volume flow in the radial artery. On the whole, the arteriovenous fistulas worked in 39 patients (75%) and did not function in 13 patients (25%). In group B, surgeons followed the color Doppler ultrasonographic results. Of 72 patients who underwent the procedure, 68 patients (94.4%) had functioning fistulas, whereas 4 (5.6%) had fistulas that did not work. These 4 patients were found to have low volume flow in the radial artery. When both groups were compared by chi2 analysis, the difference was statistically significant (P = .002). Group B, in which patients were preoperatively evaluated by color Doppler ultrasonography, had a high success rate. We found that color Doppler ultrasonography is very helpful as a noninvasive procedure for this evaluation. Although many surgical clinics still perform arteriovenous fistula construction without the aid of color Doppler ultrasonographic findings, we think that the use of color Doppler ultrasonography should be emphasized before surgeons proceed with arteriovenous fistula construction.

Normal Diaphragmatic Motion and the Effects of Body Composition Determination With M-Mode Sonography

Objective. To evaluate the quantitative measurement of diaphragmatic motion in healthy subjects and to investigate the effects of different variables such as body mass index and waist circumference on the diaphragmatic motion. Methods. The study included 164 healthy subjects. The subjects were grouped according to age, sex, body mass index, and waist circumference. Measurements of diaphragmatic motion were made by a 3.5‐MHz sonographic unit in the M‐mode of the system. The posterior diaphragm on both sides was identified, and measurements were performed during deep inspiration. Results. The mean diaphragmatic motion measurements ± SD were 49.23 ± 10.98 and 50.17 ± 11.73 mm on right and left sides, respectively. Female subjects had statistically significantly (P < .05) decreased diaphragmatic motion (right, 46.93 ± 10.37 mm; left, 47.57 ± 10.36 mm) than male subjects. The mean diaphragmatic motion (right, 40.90 ± 8.89 mm; left, 39.37 ± 9.15 mm) was less in subjects who were underweight (P < .05) when compared with subjects who were of normal weight, overweight, and obese. Subjects who had a waist circumference of less than 70 cm showed a statistically significant decrease (P < .05) in diaphragmatic motion (right, 42.55 ± 9.12 mm; left, 42.24 ± 9.73 mm) when compared with subjects who had a waist circumference of 70 to 85, 85 to 100, and greater than 100 cm. Also, subjects younger than 30 years had statistically significantly (P < .05) decreased diaphragmatic motion (right, 44.57 ± 10.57 mm; left, 44.44 ± 11.37 mm). Conclusions. Sex, body mass index, waist circumference, and age may affect the diaphragmatic motion to some extent. Healthy persons of younger age with a smaller body mass index and waist circumference may show a decreased amount of diaphragmatic motion.

Embolization of profunda femoris artery branch pseudoaneurysms with ethylene vinyl alcohol copolymer (Onyx)

This report describes the use of a new embolic agent, Onyx, which is composed of ethylene vinyl alcohol copolymer dissolved in 8% dimethyl sulfoxide, in the endovascular transcatheter embolization of traumatic profunda femoris artery branch pseudoaneurysms in three cases. Two of the cases involved massive thigh swelling after penetrating injury and the other involved massive hemorrhage at the site of a surgical fixator pin. Diagnostic angiography revealed pseudoaneurysm formation of the profunda femoris artery branches in all cases. Immediate control angiography after the embolization procedures demonstrated complete closure of the pseudoaneurysms. During the follow-up period there was no recurrent bleeding. The advantages of Onyx over conventional liquid embolic agents and coils are discussed.

Emergency Endovascular Management of Pulmonary Artery Aneurysms In Behçet’s Disease: Report of Two Cases and a Review of the Literature

his report describes two patients with a known history of Behçet’s disease in whom massive hemoptysis developed from rupture of pulmonary artery aneurysms. The high recurrence rate of complications related to pulmonary artery aneurysms and even the aneurysms themselves due to inadequacy of medical therapy and the disadvantages of surgical treatment make these aneurysms candidates for endovascular management. The pulmonary artery aneurysms reported here were successfully treated with endovascular embolization using n-butyl cyanoacrylate. Pulmonary artery aneurysm embolization in Behçet’s disease has been reviewed in the light of relevant literature.

Enteroclysis findings of intestinal Behcet disease: a comparative study with Crohn disease

AbstractBackground: The aim of this study was threefold; to define the enteroclysis (EC) findings of intestinal involvement in Behcet disease (BD), to compare these findings with those seen in Crohn disease (CD), and to determine the relation between the duration of BD and severity of the EC findings. Methods: From 1997 to 2000, 17 BD and 50 CD cases were examined by EC examination. EC was performed with a 13-F balloon catheter via transnasal entubation. Mucosal and mural changes were evaluated. Statistical analysis was performed with the Mann-Whitney U test to determine the relation between duration of BD and severity of the EC findings. P ≤ 0.05 was considered statistically significant. Results: In 12 (70.58%) of 17 BD cases, EC demonstrated intestinal pathologic findings such as ulcerations, fold thickening, granular pattern, pseudopolyp formation, and bowel wall thickening. No statistical correlation between the severity of EC findings and the duration of BD was found. Conclusion: EC should be the radiologic method to evaluate the intestinal pathology in symptomatic BD patients. The main EC finding in BD was ulceration mostly in the aphthous form. The EC findings in BD, even in longstanding cases, are usually mild when compared with those seen in CD.

Target organ damage and changes in arterial compliance in white coat hypertension. Is white coat innocent

The aim of this study was to perform an extensive evaluation of target organ status, metabolic abnormalities and hemodynamic alterations in white coat hypertension (WCH). Fifty normotensive (NT), 90 WCH (ambulatory daytime blood pressure <135/85 mmHg) and 101 hypertensive (HT) subjects underwent extensive biochemical, echocardiographic, fundoscopic examination. In a subgroup study, arterial compliance and intima‐media thickness (IMT) were measured by Doppler ultrasound in left common carotid artery. WCH subjects were found to have higher body mass index (BMI) than the NTs (p = 0.042). Left ventricle mass index (LVMI) was greater in the WCHs than the NTs (p < 0.001), but significantly less than the HTs (p < 0.001). Hypertensive retinopathy was observed in the WCHs, but was less severe and rare compared to the HTs (13% vs 27 %). Both WCHs and HTs had high levels of urinary albumin excretion (UAE) (p = not significant). Total cholesterol was higher in WCHs than in the NTs (p = 0.04) The distensibility coefficient (DC) of the WCHs was significantly greater than the HTs (p < 0.01), while significantly smaller than the NTs (p < 0.01). The compliance coefficient (CC) of the WCHs was significantly higher than the HTs (p < 0.01), and significantly less than the NTs (p < 0.01). The IMT in the HTs was significantly higher than the WCHs (0.81 ± 0.05 vs 0.70 ± 0.04 mm; p < 0.001) and the NTs (p < 0.001). The difference between the NTs and the WCHs was not significant. Our data indicate that patients with WCH represent an intermediate group between NTs and sustained HTs where target organ damage and cardiovascular risk is concerned.

Shear wave elastography properties of vastus lateralis and vastus medialis obliquus muscles in normal subjects and female patients with patellofemoral pain syndrome

ObjectiveThe aim of our study was to define and compare the mechanical properties of the vastus lateralis (VL) and vastus medialis obliquus muscles (VMO) by the way of quantitative shear-wave elastography in male and female healthy control (HC) subjects, and in female patients with patellofemoral pain syndrome (PFPS).Materials and methodsTwenty-two healthy volunteers (11 male and 11 female) and 11 female patients with anterior knee pain were included in the study. The SWE examinations for VL and VMO were performed while the subjects were performing open kinetic chain exercises in neutral and 30° hip abduction. The contraction capacity (CC) and contraction ratio (CR) values were determined in resting and contraction phases in both hip positions.ResultsThe mean elasticity values in the CC for VL and VMO muscles were significantly higher in male HC subjects when compared to female HC subjects (p < 0.05). The CR of the VL muscle in female patients with PFPS was not significantly different than the female HC group. The CR for the VMO muscle was significantly lower in female patients with PFPS when compared to female HC subjects (p < 0.05).ConclusionsWe found a significant VMO weakness, and this method may provide quantitative data that might influence the diagnosis of muscle weakness, in female patients with PFPS.

Shear wave elastography in the evaluation of liver fibrosis in children.

Background: Shear-wave elastography (SWE) is a novel noninvasive method that involves application of local mechanical compression on soft tissue using focused ultrasonography and acquiring strain images that show tissue response. In this study, our goal was to assess the performance of SWE in the staging of liver fibrosis in children with chronic liver disease. Methods: The study involved measuring SWE values in the right lobe of the liver in a patient group of 76 children with chronic liver disease and a control group of 50 healthy subjects. In the patient group, the shear elastic modulus values were correlated with biopsy results according to the Brunt scoring system (F0: portal fibrosis, F1: perisinusoidal or portal/periportal fibrosis, F2: both perisinusoidal and portal/periportal fibrosis, F3: bridging fibrosis, and F4: cirrhosis). Performance of SWE in estimating liver fibrosis in children was determined based on a receiver-operating characteristics (ROC) analysis. Results: Mean SWE values of the control group and F0 group were not statistically significantly different (P = 0.106). The mean SWE values of the F1, F2, F3, and F4 groups were higher than that of the control group (all P < 0.001). Based on kiloPascal measurement values, the area under the ROC curve was 95.2% (95% confidence interval [CI] 92.1–99.5), with a sensitivity for diagnosing liver fibrosis of 91.5%, a specificity of 94.0%, a positive predictive value of 93.1%, and a negative predictive value of 92.6%. Based on meter-per-second measurement values, the area under the ROC curve was 96.3% (95% CI 92.7–99.8), with a sensitivity for diagnosing liver fibrosis of 93.2%, a specificity of 94.0%, a positive predictive value of 93.2%, and a negative predictive value of 94.0%. Mean SWE values for patients with nonalcoholic steatohepatitis were higher than those in the remainder of the study group. Conclusions: Although liver fibrosis can be detected using SWE, differentiation of fibrosis stages could not be achieved. The presence of steatosis significantly increased the mean SWE values on elastography and so care should be taken when assessing children with nonalcoholic steatohepatitis.

Interscalene brachial plexus block with bupivacaine and ropivacaine in patients with chronic renal failure: diaphragmatic excursion and pulmonary function changes.

In this randomized, double-blind study, we compared the anesthetic characteristics and pulmonary function changes of 0.33% bupivacaine and 0.33% ropivacaine used for interscalene brachial plexus (IBP) anesthesia in patients with chronic renal failure. Forty-two patients undergoing IBP anesthesia for creation of arteriovenous fistulas were randomly allocated to receive either 30 mL of 0.33% bupivacaine (Group B) or 0.33% ropivacaine (Group R). Block onset time, diaphragmatic excursion (ultrasonographic evaluation), and free plasma concentrations of bupivacaine and ropivacaine were evaluated. Negative motion or immobility of the ipsilateral hemidiaphragm and a decrease of >10 mm in positive motion were defined as diaphragmatic paresis. The pulmonary function variables were measured by bedside spirometry equipment. Seven patients needed supplemental local anesthetic, one with total spinal block; these patients were excluded from the study. The success rate was 80.9%. Block quality was similar in the two groups. Ipsilateral hemidiaphragmatic excursion was decreased in both groups compared with baseline values (P < 0.05). Diaphragmatic paresis was identified in 10 of 16 patients and 8 of 18 patients in Groups B and R, respectively (P > 0.05). Pulmonary function significantly decreased from baseline in both groups (forced vital capacity (FVC) 30%, forced expiratory volume at 1 second (FEV1) 32%, and peak expiratory flow (PEF) 31% in Group B and FVC 17%, FEV1 17%, and PEF 5% in Group R) (P < 0.001). The decreases in Group B were larger than those in Group R (P < 0.05). Three patients in Group B and one in Group R had mild respiratory problems (P > 0.05). Concentrations of bupivacaine and ropivacaine were below toxic levels rather than “normal range.” We conclude that pulmonary function decreased more after IBP with 0.33% bupivacaine than with 0.33% ropivacaine.

Percutaneous drainage for treatment of infected pancreatic pseudocysts.

Background Infection of pancreatic pseudocysts is a potentially fatal complication that must be treated immediately. Despite numerous published reports about percutaneous treatment, the effectiveness of percutaneous catheter drainage (PCD) of infected pancreatic pseudocysts is still under discussion. Methods In this study, 30 patients (17 women) with 30 infected pancreatic pseudocysts were administered local anesthesia and underwent PCD performed with the use of a single-step trocar technique with computed tomographic guidance. The patients’ ages varied from 27 to 74 years (mean age, 45 yr). The etiology was acute pancreatitis in 18 patients, chronic pancreatitis in 11 patients, and surgical trauma in 1 patient. Results No complications related to the procedure occurred in our series. The success rate was 96% (29 of 30 patients), with no recurrence during follow-up, which ranged from 2 to 58 months (mean follow-up, 27.2 mo). One patient had unsuccessful PCD and was subsequently treated surgically. Conclusion Our findings indicate that PCD is a safe and effective front-line treatment for patients with infected pancreatic pseudocysts.