ISSN: 2149-2247 | E-ISSN: 2149-2549
ERCİYES MEDICAL JOURNAL - Erciyes Med J: 44 (4)
Volume: 44  Issue: 4 - 2022
INVITED REVIEW
1.Impact of COVID-19 Outbreak on Medical Education and Future Trends
Zeliha Kocak Tufan
doi: 10.14744/etd.2022.69260  Pages 355 - 359
The coronavirus 2019 pandemic has been a harsh reminder of the immense importance of the healthcare system. Daily life was severely disrupted and widespread effects remain ongoing. War and other circumstances can also lead to sudden disrup-tion and increased demand on medical professionals while creating significant additional challenges. Medical students are an important part of the healthcare delivery structure, and this should be recognized by both the students and the healthcare system, including medical schools. Training should include a broad range of exposure, from contact with patients and families to laboratory work and research techniques, and more in order to provide a comprehensive view and adequate preparation. Medical education has evolved greatly over time and will continue to develop according to needs and conditions. There are numerous influences, both internal and external. The medical community faces many challenges, but provides a vital service. Several portents indicate the need to adapt in order to adequately prepare for the future.

ORIGINAL ARTICLE
2.The Effect of Protein Supplementation on Body Growth Indices and Immune System Development in Premature Neonates with Very Low Birth Weight
Majid Hamidi, Roya Choopani, Elaheh Saghaei Dehkordi
doi: 10.14744/etd.2021.28159  Pages 360 - 366
Objective: Complications in very low birth weight (VLBW) infants include an increase in mortality, sepsis, failure to thrive, and immune system development disorder. However, breast milk is the preferred choice for premature infants. However, no useful nutrition support exists for well-being growth in preterm infants, especially in protein quantity. Thus, this study aims to add protein supplements to breast milk for increased growth criteria and the development of the immune system.
Materials and Methods: This double-blind clinical trial included 30 VLBW infants whose weight was <1,500 g and with ges-tational age <32 weeks. The infants were divided into three equal groups (n=10). Groups A and B received 4.8 and 3.5 gm/kg/day, respectively. However, group C was without supplement. Growth criteria (e.g., daily weight and head circumference) and weekly length were measured in all groups. Moreover, the blood sample was given pre (day 1) and post (day 21) study to analyze white blood cells, neutrophils, lymphocyte, immunoglobulin G, immunoglobulin M, and immunoglobulin A (IgA).
Results: Based on the results of the current study, a dose of 4.8 g/kg/day of protein supplement caused a significant in-crease in weight and head circumference but did not affect length development. Furthermore, receiving high-dose protein supplements caused an increase in neutrophil and lymphocyte count and serum IgA concentration.
Conclusion: Receiving high-dose protein supplement caused the development of growth criteria and the development and evolution of immune system criteria especially the innate immune system that caused decrease infectious diseases such as sepsis.

3.Effect of Inhaler Training on Self-Care Agency and Self-Efficacy of COPD Patients: A Randomized Controlled Trial
Çiğdem Ergin, Gamze Muz, Hanife Özçelik
doi: 10.14744/etd.2021.64160  Pages 367 - 374
Objective: The aim of this randomized controlled trial was to investigate the effect of inhaler technique training on the self-care agency and self-efficacy level of patients with chronic obstructive pulmonary disease (COPD).
Materials and Methods: Sixty-seven patients were randomized and recruited. Thirty-four patients were allocated to an intervention group and 33 to a control group. The study data were collected using a questionnaire form, the COPD Self-Efficacy Scale (CSES), the Exercise of Self-Care Agency Scale (ESCAS), the Medical Research Council Dyspnea Scale, and the modified Borg Dyspnea Scale. Interim and final follow-up was conducted with both groups 1 month and 3 months after the initial visit.
Results: In the final follow-up, it was observed that the majority of the patients (91.2%) in the intervention group used their inhaler drugs correctly. The intervention group dyspnea scores were better than those of the control group (p<0.05). In addition, the mean score of all subdimensions of the CSES and the total ESCAS score showed increased in the intervention group (p<0.05).
Conclusion: The findings indicated that inhaler training reduced the incorrect use of inhaler medication and the dyspnea experienced patients with COPD, and also improved self-care agency and self-efficacy.

4.Assessment of P Wave Peak Time and P Wave Dispersion in Patients with COVID-19 Infection
Şaban Keleşoğlu, Deniz Elçik
doi: 10.14744/etd.2021.06791  Pages 375 - 381
Objective: This study aims to evaluate P wave distribution (PD) and P wave peak time (PWPT) in COVID-19 patients.
Materials and Methods: A total of 140 participants were recruited in our study. The COVID-19 group included 74 subjects, and the control group included 66 individuals. Between the two groups, PD was compared for electrocardiographic P-wave measurements, including abnormal P wave axis, P wave terminal force in V1 (PWTF), P wave max duration (Pmax), and PWPT.
Results: It was determined that the Pmax and PD values of the patients infected with the COVID-19 virus were higher than the control group (p<0.001). PWPTD2 (p<0.001), PWPTV1 (p<0.001) and abnormal P wave axis ratio (p<0.05) were found to be significantly longer in COVID-19 patients. Serum CRP and WBC values were found to be significantly higher in COVID-19 patients (p<0.001, p<0.001, respectively). Also, a significant and positive correlation was detected between CRP and Pmax, PD, PWPTD2 and PWPTV1. There was the same correlation relationship between WBC with Pmax, PD, PWPTD2 and PWPTV1.
Conclusion: Significant prolongation of PWPT and PD in COVID-19 patients may be predictive in determining the risk of developing atrial fibrillation.

5.Evaluation of the Relationship Between Rosacea Cutaneous Subtype and Meibography Findings
Funda Kemeriz, Emel Erdal Çalıkoğlu, Erdoğan Yaşar, Uğur Gürlevik, Gülhan Aksoy Saraç
doi: 10.14744/etd.2021.62343  Pages 382 - 386
Objective: Acne rosacea (AR) is a chronic inflammatory skin disease that can cause serious ocular complications. This study was designed to evaluate dry eye disease (DED) and meibomian gland dysfunction (MGD) in AR patients and to investigate the relationship between the cutaneous subtype of AR and ocular involvement.
Materials and Methods: This study included 67 participants with AR and 50 healthy individuals. Patients diagnosed with 3 cutaneous subtypes were examined: erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), and phymatous ro-sacea (PR). An ophthalmatological examination was performed that included an evaluation of lid margin alterations due to mei-bomian gland (MG) obstruction, Ocular Surface Disease Index assessment, tear film break-up time testing, Schirmer testing, and a corneal conjunctival fluorescein staining assessment. Meibography was used to evaluate the upper and lower lids for MG loss.
Results: Findings in the AR group revealed MGD in 45.5% and DED in 28.1%. The meibomian gland loss rate (MGLR) was 38.7±16.9% and the meibomian gland loss grade (MGLG) was 1.57±0.82%. The rate of MGLR and MGLG was sig-nificantly greater in the AR group than in the control group (p<0.001). PPR was seen in 59.7% of the 67 patients, ETR in 29.9%, and PR in 13.4%. A comparison of the MGD, MGLR, MGLG, and presence of DED in the 3 cutaneous subtype groups yielded statistically insignificant results.
Conclusion: AR can affect MG morphology, which may result in MGD or DED. Though we did not find a significant difference in the ocular findings by subgroup, ocular involvement is a recognized risk in AR. Ophthalmologists and der-matologists should cooperate in the evaluation of AR patients. Additional studies to further examine the effects in subtype groups are recommended.

6.Evaluation of Stereopsis in Children with Corrected Anisometropia According to Type, Severity, and Presence of Amblyopia
Funda Dikkaya, Sevil Karaman Erdur
doi: 10.14744/etd.2022.07742  Pages 387 - 391
Objective: This study was designed to determine the level of stereopsis in anisometropic children with and without amblyopia who used corrective glasses and to investigate the effect of the type and magnitude of anisometropia on the level of stereopsis.
Materials and Methods: The medical records of 256 children with a diagnosis of non-amblyopic anisometropia or anisome-tropic amblyopia, and healthy controls were retrospectively reviewed for this study. Anisometropia was categorized into 3 groups: spherical equivalent-only anisometropia, astigmatic-only anisometropia, or combined anisometropia. The level of stereopsis was measured using the Titmus stereo test, compared between groups, and the correlation of the stereopsis with the magnitude of anisometropia was analyzed.
Results: Patients in the non-amblyopic anisometropia group had a similar stereopsis level when compared with the con-trol group (55.2±41.03 and 47.2±19.8 seconds of arc, respectively; p=0.223). The level of stereopsis was significantly less in the anisometropic amblyopia group (279.4±120 seconds of arc) compared with the non-amblyopic anisometropia (55.2±41.03 seconds of arc) and control groups (47.2±19.8 seconds of arc) (p=0.008, p=0.006, respectively). A greater spherical equivalent difference between the eyes resulted in poorer stereopsis in the anisometropic amblyopia group, and com-bined anisometropia was found to be associated with poorer stereopsis levels in the nonamblyopic anisometropia (NA) group.
Conclusion: The NA patients had a similar level of stereopsis compared with controls while wearing corrective glasses. This result suggests that as long as patients have good visual acuity, stereopsis is preserved, and that refractive correction with glasses does not interfere with stereopsis in childhood anisometropia.

7.Anxiety Level of Mothers of Children Aged Under Four with Functional Constipation
Eren Yıldız, Mehmet Ali Narsat, Zuhal Koç Apaydın
doi: 10.14744/etd.2022.16689  Pages 392 - 397
Objective: The aim of this study was to investigate the relationship between functional constipation in young children and their mothers’ symptoms of anxiety, with an assessment of demographic characteristics.
Materials and Methods: Sixty patients aged <4 years with constipation diagnosed based on the Rome IV criteria and 45 healthy children aged <4 presented for follow-up visits between January 2021 and May 2021, and their mothers were in-cluded in the study. The mothers were interviewed in a face-to-face meeting and completed a sociodemographic data form, the Beck Anxiety Inventory, and the State-Trait Anxiety Inventory.
Results: The number of children in the patient group whose mothers had a primary or secondary education level was sig-nificantly higher when compared with the control group (p=0.017). The patient group also had a larger number of mothers who did not work outside the home and were the primary caregiver (p<0.001; p<0.001). The mothers of the patient group had significantly higher scores on all of the assessments (Beck Anxiety Inventory, State Anxiety Inventory, and Trait Anxiety Inventory) (p<0.001; p=0.004; p=0.004).
Conclusion: The anxiety of the mother may influence the development of constipation in children, and constipation may also increase the mother’s anxiety. Incorporating psychosocial support for the family might be helpful in the treatment of functional constipation in young children.

8.Relationship of Retinal Vessel Caliber to Arterial Stiffness Parameters and Nocturnal Blood Pressure Dipping Status in Essential Hypertension
Soner Güven, Abdullah Burak Uygur, Kenan Sağlam, Fatih Bulucu, Ali Hakan Durukan
doi: 10.14744/etd.2022.18828  Pages 398 - 404
Objective: The primary aim of this study was to compare the retinal vessel caliber (RVC) with both arterial stiffness (AS) parameters and nocturnal blood pressure dipping status (DS) in essential hypertension (EH).
Materials and Methods: The retinal vessel diameter of 101 patients with EH and 31 sex- and age-matched healthy controls was measured using retinal fundus photography. Venous blood samples were obtained for biochemical tests and anthropometric measurements were also recorded. The AS parameters of carotid-femoral pulse wave velocity (cfPWV), augmentation index (AIx), and central aortic pressure (CAP) were assessed using a non-invasive TensioClinic arteriographic system (TensioMed Kft., Budapest, Hungary). DS was evaluated using 24-hour ambulatory blood pressure measurements. The baseline characteristics, AS parameters, and the nocturnal DS of hypertensive patients were statistically compared with those of healthy individuals according to RVC values.
Results: The hypertensive group had significantly higher heart rates (p=0.023); AS parameters (PWV [p<0.001], CAP [p<0.001]); and fasting glucose (p=0.028), creatinine (p=0.046), triglyceride (p=0.045), uric acid (p=0.014) and microalbumin-uria (p=0.004) values than the healthy controls. Although there was a significant positive linear correlation between the duration of hypertension and PWV (p=0.024), AIx (aortic) (p=0.005) and AIx (brachial) (p=0.013), no significant difference between the EH patients and the control subjects was observed in the AS parameters and nocturnal DS values according to the RVC value.
Conclusion: The results of this study did not demonstrate a significant correlation between the RVC and the AS parameters and nocturnal DS in EH. Additional prospective studies are warranted to reach a consensus on the clinical significance of RVC measurements in EH.

9.Determination of Depression, Anxiety and Stress in Pregnancy During the COVID-19 Pandemic
Fatma Yıldırım, Nevin Günaydın, Mevlüde Alpaslan Arar
doi: 10.14744/etd.2022.40035  Pages 405 - 410
Objective: This study aims to determine the depression, anxiety and stress in pregnant women during the 2019 Coron-avirus Disease (COVID-19) pandemic.
Materials and Methods: The sample of this descriptive study consisted of 203 pregnant women reached over online between May 15 and June 1, 2020. To collect data in the study, the ‘Personal Information Form’, ‘COVID-19 Pandemic-Related Information Form’ and ‘Depression, Anxiety, Stress Scale-21 (DASS-21)’ were used.
Results: In our study, it was determined that 81.7% of the pregnant women experienced anxiety, 56.1% depression and 24.1% stress, according to the median values obtained from DASS-21. The median values of anxiety and stress of unem-ployed women were higher than those of working women and the difference between them was statistically significant (p=0.011; p=0.023). The differences between social media use (p=0.044; p=0.048; p=0.015), thinking that they are positive for COVID-19 (p=0.009; p=0.014; p=0.001), thoughts about the end of the COVID-19 pandemic (p=0.001; p=0.001; p=0.001), worrying about their own health and the fetus (p=0.001; p=0.001; p=0.001), and experiencing ab-normal physical symptoms (p=0.001; p=0.001; p=0.001) had statistically significant effects on the anxiety, depression and stress subscale median values of pregnant women.
Conclusion: Pregnant women were found to experience depression and anxiety during the COVID-19 pandemic. It is con-sidered that knowing the negative psychosocial reactions experienced by pregnant women during the COVID-19 pandemic and taking protective measures will contribute to improving the health outcomes of the mother and the fetus.

10.Evaluation of Serum Growth Arrest-Specific 6/ Soluble AXL Levels in Type 2 Diabetes Mellitus
Merve Özel, Gülden Başkol, Amir Hossein Abedi, Yasemin Atıcı, Hatice Saraçoğlu, Neslihan Sungur, Fahri Bayram
doi: 10.14744/etd.2022.45403  Pages 411 - 415
Objective: The aim of this study was to investigate an association between serum growth arrest-specific 6 (Gas6), AXL, and soluble AXL (sAXL) levels and the glycosylated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR) in diabetic patients.
Materials and Methods: This study included type 2 diabetes mellitus (T2DM) patients of a department of endocrinology and healthy individuals. The HbA1c and creatinine levels of all of the participants were evaluated using autoanalyzers and the eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration formula. The Gas6, AXL, and sAXL serum protein concentrations were analyzed using enzyme-linked immunosorbent assays.
Results: The study group consisted of 51 patients (34 females and 17 males) diagnosed with T2DM and 17 healthy controls (9 females and 8 males). The Gas6, AXL, and sAXL concentrations were significantly lower in the patient group (p<0.05). There was a significant positive correlation between the Gas6, AXL, and sAXL parameters in both groups. The eGFR was negatively correlated with the Gas6 and sAXL levels in the patient group (r=-0.285, p<0.047; r=-0.311, p<0.028, respec-tively), while there was no correlation observed in the control group.
Conclusion: Gas6, AXL, and sAXL have an important role in the pathogenesis of T2DM. Gas6 and sAXL appear to have a potentially predictive value for diabetic nephropathy. Further clinical studies are necessary to clarify this mechanism.

11.Anesthetic Approach and Perioperative Complications in Cleft Lip/Palate Surgery: A Single Center Retrospective Study
Murat Tümer, Aysun Ankay Yilbas, Merve Göknur Soysal Kaya, Bensu Karakoyak, Kayacan Kaya, Özgür Canbay
doi: 10.14744/etd.2022.98958  Pages 416 - 422
Objective: The objective of this study was to determine factors that may affect anesthesia and surgical complications, diffi-cult airway, and the need for intensive care unit (ICU) care in cleft lip and cleft palate (CLCP) surgeries.
Materials and Methods: The study was a retrospective review of the records of 617 patients who underwent CLCP surgery between 2015–2019.
Results: The number of anesthesia complications was higher in patients with difficult mask ventilation. Surgical complica-tions were more common in patients >1 year of age. Isolated cleft palate (CP) surgery; presence of a concomitant disease, syndrome, or micrognathia; age >1 year; and the CP subtype were associated with a higher rate of difficult intubation. Iso-lated cleft palate, concomitant disease, syndrome, micrognathia, difficult intubation, difficult mask ventilation, and anesthesia complications were associated with ICU admission.
Conclusion: The CP subtype was associated with a higher rate of difficult intubation and ICU hospitalization even in pa-tients who were nonsyndromic and/or >1 year of age. Therefore, special attention should be paid to the anesthesia and surgical management of these patients.

12.Clinical Characteristics and Outcomes of Infants Born to Mothers with COVID-19 Infection and Those with COVID-19 Infection: A Cross-sectional Study
Berna Saygın Hekimoğlu, Filiz Aktürk Acar
doi: 10.14744/etd.2022.44969  Pages 423 - 429
Objective: The aim of this study is to evaluate the risk factors, clinical findings, treatment methods and short-term outcomes of infants born to mothers with COVID-19 infection and infants with COVID-19 infection.
Materials and Methods: Data of infants born to mothers with COVID-19 infection and infants with COVID-19 infection treated in our Newborn Intensive Care Unit between 1 March 2020 and 1 April 2021 were retrospectively reviewed.
Results: A total of 60 newborns were included in the study. Of these, 46 were born to mothers with COVID-19 infection, the gestational week was 36.8±3.3 weeks, 28 were girls. All newborns born to mothers with COVID-19 tested negative for reverse transcriptase-polymerase chain reaction (RT-PCR). The premature birth rate was 30%, the low birth weight rate was 19.4%, maternal mortality was 8.7% and neonatal mortality was 2.2%. 14 of the infants included in the study had community-acquired COVID-19 infection, the gestational age was 38.9±0.9 weeks, 6 of them were girls. The most frequent clinical findings were fever and runny nasal discharge. Most neonates in both groups were formula-fed (65.2% vs. 64.3%, respectively).
Conclusion: We found that pregnant women with COVID-19 infection had a higher maternal mortality rate, preterm birth, and caesarean section. Families should be informed and encouraged about breast milk and breastfeeding during the COVID-19 pandemic.

CASE REPORT
13.Plasma Exchange in the Treatment of A Child with West Nile Virus Encephalitis: A Case Report
Yasemin Özkale, Murat Özkale, Özgür Ceylan, Ilknur Erol
doi: 10.14744/etd.2021.96606  Pages 430 - 433
Background: West Nile virus (WNV) is a member of the Japanese encephalitis antigenic complex of the family Flaviviridae that can cause a wide range of clinical symptoms, from asymptomatic disease to severe meningitis, encephalitis flaccid paral-ysis, and death. In immunocompetent children, WNV infection is usually benign and self-limiting. However, this virus is also associated with severe neurological disease in some patients, especially those who are older, have a chronic disease, have undergone organ transplantation, or are immunocompromised.
Case Report: A 12-year-old boy with selective immunoglobulin A-deficiency (SIgAD) and refractory seizures due to WNV encephalitis (WNE) was successfully treated with therapeutic plasma exchange (TPE) in conjunction with other immunomod-ulatory therapies.
Conclusion: WNV can progress like autoimmune encephalitis. TPE appears to be safe and effective for treating children with WNE. To our knowledge, this report is the first of a child with WNV infection and SIgAD.

14.Rare Presentation of a Common Hematological Malignancy
Anirudh J Shetty, Sujit Janardhanan, Rimesh Pal
doi: 10.14744/etd.2021.36048  Pages 434 - 436
Background: Metastatic spinal cord compression (MSCC) is a well-recognized complication of underlying malignancies; however, MSCC is rarely seen in acute leukemia.
Case Report: A 24-year-old female presented with low backache, right lower limb radicular pain, right foot drop, and loss of bladder sensation, suggestive of cauda conus syndrome. Magnetic resonance images revealed an enhanced pre-/paraver-tebral lesion extending from the L5-S3 level with destruction of the vertebral body and intraspinal infiltration. A peripheral blood smear revealed atypical cells, which bone marrow analysis confirmed to be vacuolated myeloblasts. A diagnosis was made of acute myeloid leukemia (AML) type M4 with spinal myeloid sarcoma leading to cord compression. A cytarabine and doxorubicin-based chemotherapy regimen was initiated. Her symptoms improved after 2 cycles, however, she developed febrile neutropenia after 4 cycles of treatment and died.
Conclusion: MSCC, although rare, can be a presenting complaint of AML resulting from cord compression due to spinal myeloid sarcoma.

IMAGE
15.A Rare Cause of Severe Dyspnea and Right Upper Quadrant Pain: Tension Hydrothorax
Furkan Ufuk, Hakkı Peker, Gökhan Öztürk
doi: 10.14744/etd.2022.40121  Pages 437 - 438
Abstract | Full Text PDF

HISTORY OF MEDICINE
16.A Historical Perspective of the Management of Scoliosis
Gözde Yağcı, Nilgün Bek
doi: 10.14744/etd.2022.23682  Pages 439 - 446
Efforts to treat spinal deformity have a long and fascinating history. The ancient Greek physicians Hippocrates and Galen are credited with early descriptions of the condition, management, and the term scoliosis, though even earlier references are seen in Hindu epics. The first known treatment techniques used axial traction and pressure. Subsequent cast correction required fixation of the pelvis and flattening of lumbar lordosis. Bracing superseded traction as the primary means to treat spinal deformities in the 1900s. The first spinal fusion surgery was performed in the 20th century. Scoliosis treatment was greatly improved with the recognition of the 3-dimensional nature of scoliosis and its symptoms. Advances in nonsurgical treatment alternatives included the Milwaukee brace and the subsequent development of underarm plastic braces, such as the Boston brace, the Wilmington brace, and the Chêneau brace. Today, treatment options include bracing, and scoliosis-specific exercises selected according to the curve type and severity, in addition to surgery.

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