Publications by authors named "Hakan Demirci"

234 Publications

Investigation of the effects of diabetes mellitus on left internal thoracic artery flow patterns in patients scheduled to undergo coronary bypass graft surgery.

J Clin Ultrasound 2022 May 27. Epub 2022 May 27.

Department of Cardiovascular Surgery, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey.

Purpose: Diabetes mellitus (DM) plays a key role in the formation and prognosis of cardiovascular diseases. In this study, we aimed to investigate the effects of DM and glycemic control on left internal thoracic artery (LITA) Doppler flow in patients scheduled to undergo coronary artery bypass graft (CABG) surgery.

Methods: Patients who were hospitalized with a planned isolated CABG operation to our clinic between October 1, 2019 and March 1, 2020 were consecutively included in this prospective study. The patients were divided into three groups as those without DM (Group 1), those with DM and HbA1c values of below 7.5 (Group 2), and those with DM and HbA1c values of 7.5 and above (Group 3). The differences between the LITA Doppler flow patterns of the patients were analyzed.

Results: The mean ages of Group 1 (n = 103), Group 2 (n = 42), and Group 3 (n = 47) were 59.8 ± 9.6 years, 60.5 ± 9.3 years, and 61.9 ± 8.1 years, respectively. The groups differed in terms of diameter, volume, Vmax, pulsality index (PI), and resistive index (RI) values, both when the groups were compared among themselves (P < .001, for all), and when they were compared between those with (Groups 2 and 3) and without DM (Group 1) (P < .001, for all). Volume (R = -0.627, P < .001) and Vmax (R = -.450, P < .001) were moderately negatively correlated, while PI (R = .523, P < .001) and RI (R = 0.598, P < 0.001) were moderately positively correlated with HbA1c levels.

Conclusion: In this study, we showed that increased HbA1c levels may be associated with significant functional and structural changes of LITA.
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http://dx.doi.org/10.1002/jcu.23241DOI Listing
May 2022

Bilateral exudative retinal detachments and associated choroidal detachments in a patient on dapsone: a case report.

Int J Retina Vitreous 2022 May 20;8(1):31. Epub 2022 May 20.

Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall St, Ann Arbor, MI, 48105, USA.

Background: Dapsone is a synthetic sulfonamide used to treat numerous dermatologic conditions. Ocular side effects have been rarely reported and include retinal necrosis, optic atrophy, and macular infarction. We report the first known case of bilateral choroidal effusions and exudative retinal detachments associated with dapsone use.

Case Presentation: A 57-year-old male with a past medical history of testicular seminoma presented with bilateral blurry vision for 2 months. His exam revealed bilateral choroidal effusions with bilateral exudative retinal detachments without evidence of intraocular tumor. The patient had recently been prescribed dapsone for urticarial vasculitis. The patient was instructed to discontinue dapsone and follow-up closely. Interval follow-up of 8 months demonstrated almost complete resolution of the choroidal effusions and retinal detachments with residual pigment epithelium changes after cessation of dapsone. The patient recovered his pre-detachment visual function.

Conclusions: Patients on dapsone who present with new visual complaints should undergo a thorough ophthalmic evaluation given the multiple mechanisms by which dapsone can affect the eye.
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http://dx.doi.org/10.1186/s40942-022-00383-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9123782PMC
May 2022

Helicobacter Pylori Colonization Density is an Important Risk Factor for Eradication Therapy.

J Gastrointestin Liver Dis 2022 Jun 12;31(2):163-167. Epub 2022 Jun 12.

Department of Gastroenterology, Healty Sciences University, Gulhane Training and Research Hospital, Ankara.

Background And Aims: Despite the known risk factors, it is not clear why the same treatment protocol for Helicobacter pylori infection (H. pylori) doesnot show a similar effect in patients with common risk factors. We hypothesized that as the severity of H. pylori - induced gastric mucosa inflammation and density increase, the rate of successful treatment decreases. This study aimed to explore the existence of a possible association between gastric H. pylori colonization density and the efficacy of bismuth-containing quadruple eradication therapy.

Methods: A total of 330 patients with H. pylori positive gastritis were initially included; the diagnosis was based on the histopathological examination. H. pylori colonization density was graded according to the Sydney classification: mild (n=101), moderate (104) and severe (98). H. pylori eradication was determined via the 13C-Urea breath test performed eight weeks after therapy.

Results: There was no significant difference in terms of the distributions of age, gender, alcohol consumption, and smoking status among the groups (p>0.05). The successful eradication rates of H. pylori were 87.1%, 78.8%, and 75.5%, respectively, for the mild, moderate, and severe H. pylori colonization groups by per-protocol analysis (p=0.038). The eradication rates of H. pylori were 81.5%, 73.2%, and 67.3% respectively, for the mild, moderate, and severe H. pylori colonization groups by intention-to-treat analysis (p=0.017).

Conclusions: Helicobacter pylori colonization severity might predict the usefulness of eradication therapy in pre-treatment assessment. We recommend the use of more effective therapy regimens for H. pylori eradication in patients with severe densities.
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http://dx.doi.org/10.15403/jgld-4238DOI Listing
June 2022

Cemiplimab for Orbital Squamous Cell Carcinoma in 11 Cases.

Ophthalmic Plast Reconstr Surg 2022 May 3. Epub 2022 May 3.

Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven.

Purpose: To review the demographics, clinical features, and response of orbital squamous cell carcinoma treated with cemiplimab.

Methods: This is a retrospective multi-institutional series. Patient characteristics, drug dosing, duration, and response to treatment were evaluated.

Results: The study cohort consisted of 11 patients from 5 institutions. All patients received a regimen of 350 mg q 3 weeks and an average of 11.2 cycles (SD 5.8). No patient experienced significant side effects requiring treatment or cessation of cemiplimab. Complete response was achieved in 9 patients (82%) treated with cemiplimab.

Conclusions: Immune checkpoint inhibitors, such as cemiplimab provide a globe-sparing option for the treatment of orbital squamous cell carcinoma. It is important to consider these agents especially when orbital exenteration is the alternative.
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http://dx.doi.org/10.1097/IOP.0000000000002190DOI Listing
May 2022

A case of ciliary body cyst with extrascleral extension.

J AAPOS 2022 Apr 15. Epub 2022 Apr 15.

Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor. Electronic address:

We report the case of a 3-year-old girl who presented with an elevated, darkly colored, subconjunctival lesion found to be a ciliary body cyst with extrascleral extension. The patient was treated with excision of bulbar conjunctiva, sclera, and the ciliary body cystic lesion. The defect was repaired with a scleral patch graft. The patient had a small recurrent cyst after 15 months of postsurgical follow-up, and the procedure was repeated. There was no recurrence at follow-up 1 year after the second surgery.
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http://dx.doi.org/10.1016/j.jaapos.2022.01.007DOI Listing
April 2022

Health Literacy and Health Outcomes in Chronic Obstructive Pulmonary Disease Patients: An Explorative Study.

Front Public Health 2022 17;10:846768. Epub 2022 Mar 17.

Department of Chest Diseases, Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, University of Health Sciences Turkey, Istanbul, Turkey.

Aim: This study aimed to evaluate the relationship between health literacy (HL) and chronic obstructive pulmonary disease (COPD) severity.

Methods: Pulmonary function test, sociodemographic features, Modified Medical Research Council (mMRC) dyspnea scale, COPD assessment test (CAT), and the European Health Literacy Survey Questionnaire were used. The study examined 13,760 patients who underwent a pulmonary function test. Out of 13,760 patients, 673 patients had FEV1/FVC values less than 70%. Those with FEV1/FVC< 0.70 ( = 336) after the reversibility test were included in the study.

Results: There was a significant decrease in HL and an increase in COPD severity ( < 0.001). In multivariate analysis, the risk of severe COPD was 2.74 times higher in patients in the poor income level than in patients in the good income level. In patients with inadequate HL, the risk of developing severe COPD was 1.80 times higher. A significant difference was found in HL index scores among the groups in terms of education level and income level ( < 0.001; < 0.001, respectively). The most difficult topics for patients with COPD were periodic health examinations, good practices in mental health, and adult vaccinations.

Conclusions: Patients with COPD were found to be at a HL level well below the expected level. The risk of severe COPD increased with poor income and inadequate HL. Healthcare providers should be careful in accessing, understanding, and interpreting the health information of patients with inadequate HL. Therefore, patient education should be prioritized in the follow-up and in the treatment of patients with COPD. Physicians should pay maximum attention to patients with COPD in the regular use of drugs, their proper use, in taking preventive measures, and in adult vaccination.
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http://dx.doi.org/10.3389/fpubh.2022.846768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8970619PMC
April 2022

Improved Prognostic Precision in Uveal Melanoma through a Combined Score of Clinical Stage and Molecular Prognostication.

Ocul Oncol Pathol 2022 Feb 1;8(1):35-41. Epub 2021 Nov 1.

Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA.

Introduction: Prognosis of uveal melanoma (UM) is assessed using clinical staging or molecular testing. Two modalities often used for prognostication are the American Joint Committee on Cancer (AJCC) staging and a tumor gene expression profile (GEP), the outcomes of which are often discordant. This article discusses a total risk score created to combine the discordant information from both sources.

Methods: A retrospective case series was conducted of all patients presenting with UM over 6 years to 2 referral centers. Each tumor was classified using the AJCC and the GEP. A total risk score was calculated for each patient using results from both AJCC and GEP. Kaplan-Meier analysis of metastasis-free survival was used to compare groups.

Results: A total of 294 patients were included in the study. Kaplan-Meier estimates showed significant curve separation between individual AJCC and GEP risk groups. The combined total risk score provided an accurate estimate of prognosis that incorporated results from both AJCC and GEP.

Conclusions: Clinical staging and molecular prognostication of UM can be discordant. There is important information provided by each system that is not provided by the other. The total risk score provides a simple method to combine information from both AJCC stage and the GEP class in order to provide patients and care teams with a more complete understanding of metastatic risk.
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http://dx.doi.org/10.1159/000520218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8914271PMC
February 2022

Safety Evaluation of Photoacoustic Tomography System for Intraocular Tumors.

Transl Vis Sci Technol 2022 03;11(3):30

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI, USA.

Purpose: Photoacoustic tomography (PAT) has demonstrated the ability to characterize molecular components and architectural heterogeneities of intraocular tumors in enucleated human globes and in animals in vivo. Although laser safety levels have been established for illumination through the cornea, the safety limit for PAT illumination through the sclera has not been investigated. The purpose of this study is to examine if the energy level used in intraocular PAT results in ocular damage.

Methods: Rabbit eyes were exposed to pulsed laser illumination at 20 mJ/cm2 at the scleral surface. Eyes were examined at 1, 7, and 28 days after the laser exposure. Examination procedures included white light and fluorescence fundus imaging, optical coherence tomography (OCT), electroretinography (ERG), and histology with hematoxylin and eosin (H&E) staining as well as terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL staining).

Results: Fundus imaging and OCT of rabbit eyes at 1, 7, and 28 days following exposure of the laser illumination of the PAT system did not reveal any damage to the retinal structures. ERG showed no significant difference between the experimental and control eyes. Similarly, H&E histology did not show abnormalities in either the scleral tissue where the laser illumination was delivered or in the retinal layers. No sign of apoptosis in the layers of the retina, choroid, or optic nerve was found on TUNEL staining.

Conclusions: Similar to the application of PAT to other organs, the proposed laser illumination energy level at 20 mJ/cm2 does not impose detectable harm to the ocular tissue.

Translational Relevance: This study addresses illumination safety issues for PAT.
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http://dx.doi.org/10.1167/tvst.11.3.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8976930PMC
March 2022

Treatment of Choroidal Hemangioma with Photodynamic Therapy and Bevacizumab.

Ophthalmol Retina 2022 Jun 1;6(6):533-535. Epub 2022 Feb 1.

Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.oret.2022.01.015DOI Listing
June 2022

Neurological Symptoms and Diagnoses in Patients Hospitalized With COVID-19: Relationships With Mortality.

Neurologist 2021 Nov 4;26(6):237-243. Epub 2021 Nov 4.

Anesthesiology and Intensive Care, Bursa City Hospital.

Background: Coronavirus disease 2019 (COVID-19) is a disease that affects many organs, especially the lung, and may lead to multiorgan failure. Studies describing neurological dysfunctions involving the central and peripheral nervous systems have emerged. In our study, we aimed to evaluate the neurological signs and symptoms in hospitalized patients with COVID-19.

Methods: The data of 290 patients admitted to our center (ward and intensive care unit) who received a diagnosis of COVID-19 were analyzed retrospectively. Patients' demographic, clinical and laboratory data, and their neurological diseases, symptoms, and complications were compared.

Results: Male sex, heart disease, chronic obstructive pulmonary disease and having a history of neurological disease were associated with increased mortality in patients with COVID-19. Seizures and altered consciousness were also found to be more common in patients who died. In addition, lower platelet counts (P=0.001), higher C-reactive protein levels (P<0.001) and higher D-dimer levels (P=0.003) were associated with increased risk of mortality.

Conclusions: We believe that close monitoring of any possible neurological manifestations is mandatory in hospitalized patients at the onset of COVID-19 and during disease progression. Clinical findings such as neurological symptoms and acute phase reactants are important in the follow-up and treatment of the disease.
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http://dx.doi.org/10.1097/NRL.0000000000000379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575100PMC
November 2021

Spontaneous pneumomediastinum incidence and clinical features in non-intubated patients with COVID-19.

Clinics (Sao Paulo) 2021 20;76:e2959. Epub 2021 Sep 20.

Department of Family Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey.

Objectives: To evaluate the presentation characteristics and disease course of seven patients with COVID-19 who spontaneously developed pneumomediastinum without a history of mechanical ventilation.

Methods: A total of seven non-intubated patients with COVID-19, of age ranging from 18-67 years, who developed spontaneous pneumomediastinum between 01 April and 01 October 2020 were included in the study. Patients' demographic data, clinical variables, and laboratory values were examined. Spontaneous pneumomediastinum was evaluated using posteroanterior chest radiography and thorax computed tomography.

Results: During the research period, 38,492 patients reported to the emergency department of our hospital with COVID-19 symptoms. Of these, spontaneous pneumomediastinum was detected in seven patients who had no previous history of intubation. Chronic obstructive pulmonary disease (2/7) and asthma bronchiale (2/7) were determined as the most common causes of comorbidity.

Conclusions: In our study, the frequency of spontaneous pneumomediastinum developing without pneumothorax was found to be high in non-intubated patients. Whether this is related to the nature of the disease or it is a result of the increase in cases diagnosed incidentally owing to the increasing use of low-dose computed tomography should be explored in further studies.
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http://dx.doi.org/10.6061/clinics/2021/e2959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420840PMC
September 2021

Intestinal Metaplasia Influencing the Density of Ghrelin Expressing Cells in Morbid Obese Patients.

Obes Surg 2021 12 20;31(12):5183-5188. Epub 2021 Sep 20.

University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Department of Gastrointestinal Surgery, 16310, Yildirim, Bursa, Turkey.

Purpose: The aim was to compare the density of ghrelin-expressing cells (GECs) in morbid obese patients with or without intestinal metaplasia (IM).

Materials And Methods: The study included 48 patients out of 244 who underwent laparoscopic sleeve gastrectomy between 2015 and 2019. IM was detected in the sleeve gastrectomy specimens of 24 of these 244 patients. The study group consisted of all of the patients with IM. It was a case matched study. Matching factors were age and gender. Ghrelin was stained with a Leica semiautomatic immunohistochemical-staining machine. Stained preparations with ghrelin were subjected to light microscopic examination.

Results: The number of GECs in cases with IM was significantly lower than the cases without IM (p = 0.001). The number of GECs was significantly higher in cases with chronic inactive superficial gastritis than cases with chronic active superficial gastritis (p = 0.033).

Conclusion: We found that there was a decrease in the number of GECs in the corpus and fundus of the stomach in cases with gastric IM as a contribution to the literature. IM cause a decrease in the number of GECs in the gastric oxyntic glands. In addition, chronic active superficial gastritis is also associated with a decrease in the number of GECs. We can say that the common feature of all of these factors may be gastric mucosal damage. Consequently, damage to the gastric mucosa appears to reduce the number of GECs.
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http://dx.doi.org/10.1007/s11695-021-05673-7DOI Listing
December 2021

Choroidal malignant melanoma masquerading as orbital cellulitis.

Orbit 2021 Jul 7:1-2. Epub 2021 Jul 7.

Department of Ophthalmology and Visual Sciences, W. K Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1080/01676830.2021.1916046DOI Listing
July 2021

Vismodegib for Preservation of Visual Function in Patients with Advanced Periocular Basal Cell Carcinoma: The VISORB Trial.

Oncologist 2021 07 31;26(7):e1240-e1249. Epub 2021 May 31.

Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA.

Background: Basal cell carcinoma (BCC) is a common skin cancer often curable by excision; however, for patients with BCC around the eye, excision places visual organs and function at risk. In this article, we test the hypothesis that use of the hedgehog inhibitor vismodegib will improve vision-related outcomes in patients with orbital and extensive periocular BCC (opBCC).

Materials And Methods: In this open-label, nonrandomized phase IV trial, we enrolled patients with globe- and lacrimal drainage system-threatening opBCC. To assess visual function in the context of invasive periorbital and lacrimal disease, we used a novel Visual Assessment Weighted Score (VAWS) in addition to standard ophthalmic exams. Primary endpoint was VAWS with a score of 21/50 (or greater) considered successful, signifying globe preservation. Tumor response was evaluated using RECIST v1.1. Surgical specimens were examined histologically by dermatopathologists.

Results: In 34 patients with opBCC, mean VAWS was 44/50 at baseline, 46/50 at 3 months, and 47/50 at 12 months or postsurgery. In total, 100% of patients maintained successful VAWS outcome at study endpoint. Compared with baseline, 3% (95% confidence interval [CI], 0.1-15.3) experienced major score decline (5+ points), 14.7% (95% CI, 5 to 31.1) experienced a minor decline (2-4 points), and 79.4% experienced a stable or improved score (95% CI, 62.1-91.3). A total of 56% (19) of patients demonstrated complete tumor regression by physical examination, and 47% (16) had complete regression by MRI/CT. A total of 79.4% (27) of patients underwent surgery, of which 67% (18) had no histologic evidence of disease, 22% (6) had residual disease with clear margins, and 11% (3) had residual disease extending to margins.

Conclusion: Vismodegib treatment, primary or neoadjuvant, preserves globe and visual function in patients with opBCC. Clinical trail identification number.NCT02436408.

Implications For Practice: Use of the antihedgehog inhibitor vismodegib resulted in preservation of end-organ function, specifically with regard to preservation of the eye and lacrimal apparatus when treating extensive periocular basal cell carcinoma. Vismodegib as a neoadjuvant also maximized clinical benefit while minimizing toxic side effects. This is the first prospective clinical trial to demonstrate efficacy of neoadjuvant antihedgehog therapy for locally advanced periocular basal cell carcinoma, and the first such trial to demonstrate end-organ preservation.
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http://dx.doi.org/10.1002/onco.13820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8265335PMC
July 2021

The evolution of an active solitary idiopathic choroiditis (focal scleral nodule): a case report of the natural course and a review of the literature.

BMC Ophthalmol 2021 Mar 9;21(1):130. Epub 2021 Mar 9.

Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI, 48105, USA.

Background: To describe the clinical course of an active solitary idiopathic choroiditis (focal scleral nodule) that nearly resolved over six weeks without intervention.

Case Presentation: An 18-year-old man presented to the emergency department with headaches and new onset central scotoma in the right eye. Visual acuity was 20/20 in both eyes. Fundus examination revealed an amelanotic choroidal lesion with associated shallow subretinal fluid. It measured 6.1 × 6.3 × 1.4mm on A- and B-scan. Evaluation for systemic inflammatory and infectious diseases was negative. A week later, the lesion remained stable, and a month later, there was improvement of the lesion with a decrease in size on OCT and exam and resolution of the subretinal fluid suggesting that the lesion had become inactive.

Conclusions: Solitary idiopathic choroiditis (Focal scleral nodule) is a rare condition characterized by inflammatory granulomatous reaction. This case report sheds light on the unknown natural course of a solitary idiopathic choroiditis (focal scleral nodule).
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http://dx.doi.org/10.1186/s12886-021-01888-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7942170PMC
March 2021

Reasons for the relocation of contracted family physicians and job satisfaction.

Fam Pract 2021 09;38(5):556-561

Department of Family Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Yildirim, 16310 Bursa, Turkey.

Aim: The aim of this study was to determine the reasons for the relocation of contracted family physicians and the relationship of this situation with burnout and job satisfaction status.

Methods: This study was conducted with contracted family physicians in Bursa province between May 2019 and December 2019. The physicians were visited in the family health centres where they worked. The participants were asked to fill out a socio-demographic data form, Maslach Burnout Inventory Scale and Minnesota Job Satisfaction Questionnaire. In addition, physicians who had relocated were asked to fill out a questionnaire examining the reasons for this change.

Results: The most common reasons for the relocation of physicians were distance from home (65.30%), novelty seeking (25.60%) and burnout (24.80%). Being female (P = 0.004), duration of medical experience (P < 0.001), shorter time passed in family practice (P = 0.043) and job dissatisfaction (P = 0.006) were risk factors for relocation in a regression analysis model. Receiver operating characteristic analysis revealed a cut-off point value for the Minnesota overall score as ≤3.

Conclusions: In family practice, it is favourable to provide continuity of care to the patient with the same physician. However, migration of physicians within the province for social and cultural reasons to more prosperous regions, often to where they live, was observed. Young female family doctors will probably continue to migrate to better locations within the city regardless of payment advantages in poor settlements. The roles of female physicians in society (as mother, wife and daughter) may have an effect on this preference.
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http://dx.doi.org/10.1093/fampra/cmab015DOI Listing
September 2021

The spontaneous resolution of a vortex vein varix: case report.

BMC Ophthalmol 2021 Feb 24;21(1):101. Epub 2021 Feb 24.

WK Kellogg Eye Center, Department of Ophthalmology, University of Michigan, 1000 Wall Street, 40105, Ann Arbor, Michigan, USA.

Background: The natural course of a vortex vein varix, though not well understood, has been known to remain stable. However, here we report a novel case of a vortex vein varix that resolved after an extended period of monitoring.

Case Presentation: An asymptomatic 96-year-old Caucasian man was found to have a vortex vein varix. At his previous examination 13 months prior, his fundus was normal. At 13 months of observation, his vortex vein varix become clinically undetectable. Further follow-up confirmed continued absence of the varix.

Conclusion: This case demonstrates the development then clinical resolution of a vortex vein varix with no clear identifiable factors for its evolution. This case is novel and offers new insight into the natural history of some vortex vein varices, implicating venous congestion as an instigator and venous collateralization as its alleviator, suggesting that vortex vein varices are likely more common than previously reported since some may be temporary and under-identified.
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http://dx.doi.org/10.1186/s12886-021-01861-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903696PMC
February 2021

Evaluation of Syrian refugees' emergency service admissions in the western region of Turkey.

Pathog Glob Health 2021 May 24;115(3):196-202. Epub 2021 Jan 24.

Deparment of Emergency Medicine, Health Sciences University Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey.

Immigration increases physical, mental, and social health problems. Emergency departments constitute resources that refugees can easily access and where they frequently present. Physicians from every specialty (chest diseases, thoracic surgery, internal diseases, etc.) may be consulted if needed. We aimed to compare demographic data and clinical characteristics of Syrian refugees and Turkish citizens in our emergency department. This study was an observational cross-sectional study. It included patients who presented to the Adult Emergency Department between April 1 and July 1, 2018. The patients were grouped into Syrian refugee and Turkish citizen groups. Patient age, gender, International Statistical Classification of Disease and Related Health Problems (ICD-10) diagnostic codes, and judicial case status were recorded from physician-patient outpatient clinic data records. Disease diagnoses and judicial cases were statistically compared between the two groups. A total of 30,749 patients presented to the emergency department during the study period. Of these, 999 were Syrian refugees. The mean ages of the Syrian refugees and Turkish citizens were significantly different. There were also differences between the two groups in the top five diagnostic codes (M79-Soft tissue disorders, J39-Other disorders of the upper respiratory tract; R51-Headache; R10-Abdominal and pelvic pain; M54-Dorsalgia). A comparison of the judicial cases also revealed a difference in mean age between the groups. Fewer specific disease diagnoses were identified among Syrian refugees. This may be explained by difficulties related to language barriers between the refugees and healthcare personnel.
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http://dx.doi.org/10.1080/20477724.2021.1878442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078921PMC
May 2021

Long-term follow up of systemic rituximab therapy as first-line and salvage therapy for idiopathic orbital inflammation and review of the literature.

Orbit 2022 Jun 21;41(3):297-304. Epub 2021 Jan 21.

Department of Ophthalmology and Visual Science, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA.

Purpose: To report long-term outcomes of systemic rituximab therapy for idiopathic orbital inflammation (IOI) as both primary and salvage therapy and to review the English literature.

Methods: A retrospective review of four consecutive biopsy-proven IOI cases managed with systemic rituximab including demographics, management, and outcomes, and review of English literature, were performed. Primary outcome measures included resolution of symptoms, recurrence, and length of follow up.

Results: Of four cases, systemic rituximab was the first-line therapy in two cases and salvage therapy in two cases. The mean age of the patients was 62 years (range, 50-68 years). The orbit was involved in three cases and extraocular muscle in one case. Systemic rituximab (1 g weekly for 4 weeks) was given for one session in three patients and for 12 sessions in 1 patient. All four patients responded with the resolution of all symptoms without recurrence after at least 5 years of follow up. Review of the literature showed systemic rituximab had provided clinical improvement at shorter follow up in 14 of 15 cases when used as a salvage therapy.

Conclusions: Systemic rituximab therapy seems to be an effective therapy for IOI as salvage or first-line therapy with long-term clinical durability.
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http://dx.doi.org/10.1080/01676830.2021.1874424DOI Listing
June 2022

Sleep quality and obstructive sleep apnoea and triple screen test results in pregnancy.

J Obstet Gynaecol 2021 Oct 16;41(7):1067-1070. Epub 2021 Jan 16.

Department of Family Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey.

In this study, we aimed to examine the relationship between sleep quality, sleep apnoea and triple screen test results. This was an observational descriptive research study. The STOP questionnaire and the STOP-BANG questionnaire were performed to assess obstructive sleep apnoea risk and Pittsburgh Sleep Quality Index was used to evaluate sleep quality. The average Pittsburgh Sleep Quality Index score of the participants was 5.92 ± 3.26. According to the STOP test, 11.40% (87) of the pregnant women had a high risk of OSAS, and, according to the STOP-BANG test, 32 participants were under high risk of OSAS. An increased risk was detected in 1.30% of the participants in terms of Trisomy18 and in 1.60% in terms of neural tube defects. A direct and significant relationship was detected between Trisomy 21 risk and STOP-BANG score. This is the first study to show this relationship. Sufficient evidence needs to be collected on this issue. Testing in earlier weeks of pregnancy and in the conception period may allow more meaningful assessment of the relationship of OSAS with chromosomal abnormalities.IMPACT STATEMENT There is a link between OSAS and epigenetic changes. Components of the triple screen test, levels of serum total β-hCG and unconjugated oestriol are increased in OSAS. An increase in Trisomy 21 risk is correlated with increased OSAS risk. Alpha Fetoprotein levels were higher in the low OSAS risk group. This is the first study to show this relationship. Sufficient evidence needs to be collected on this issue. Treatment of OSAS may be necessary during pregnancy.
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http://dx.doi.org/10.1080/01443615.2020.1845629DOI Listing
October 2021

A novel OCT signature in leukemic papillopathy masquerading as autoimmune or infectious uveitis.

Graefes Arch Clin Exp Ophthalmol 2021 May 4;259(5):1315-1322. Epub 2021 Jan 4.

Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA.

Purpose: With therapeutic advances, central nervous system (CNS) involvement in leukemia has become more common. Leukemic optic disc infiltration, often a clinical diagnosis, can present as an isolated finding in primary or relapsed CNS disease and therefore requires early recognition. Not previously well appreciated, we report here signs of intraocular inflammation accompanying leukemic optic disc infiltration, suggesting infectious or non-infectious uveitis as an alternative diagnosis. We describe a novel optical coherence tomography (OCT) sign favoring leukemic infiltration.

Methods: Retrospective consecutive case series of all leukemic patients with disc edema (5 patients, 6 eyes) presenting to the University of Michigan's Ocular Oncology Clinic between October 2019 and March 2020.

Results: We report five leukemic patients (6 eyes) who were evaluated for disc edema and vitritis and eventually diagnosed with leukemic papillopathy. All five patients initially had a bland lumbar puncture (LP), and all four patients who underwent magnetic resonance imaging (MRI) had no retrobulbar nerve involvement. Clinical findings included preserved visual acuity (n = 5 eyes, 83%), anterior chamber (AC) cell (n = 3 eyes, 50%), vitreous cell (n = 6 eyes, 100%), and retinal whitening (n = 4 eyes, 66%). In five eyes (83%), a diagnosis of infectious or non-infectious uveitis was initially considered. The OCT finding of inner retinal thickening and loss of inner retinal lamination with largely preserved outer retinal architecture helped point towards a leukemic infiltrative process emanating from the disc and spreading retrograde through the nerve fiber layer.

Conclusions: These cases highlight the difficulty of distinguishing intraocular inflammation associated with leukemic papillopathy from infectious or non-infectious uveitis, especially considering bland LP and negative retrobulbar MRI signal in all our patients. We propose juxtapapillary inner retinal infiltration with the loss of inner retinal lamination and relative preservation of outer retinal architecture on OCT imaging as a finding that supports the diagnosis of leukemic papillopathy.
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http://dx.doi.org/10.1007/s00417-020-05055-2DOI Listing
May 2021

Relationship between health literacy and quality of colonoscopy bowel preparation.

Turk J Gastroenterol 2020 11;31(11):799-804

Department of Gastroenterology, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey.

Background/aims: There are a variety of factors that affect the quality of colonoscopy bowel preparations, although the relationship between the level of health literacy (HL) and the quality of bowel preparations has yet to be clarified. The present study evaluated the effect of HL on the quality of bowel preparation prior to a colonoscopy.

Materials And Methods: The data of 150 patients who underwent a colonoscopy for colorectal cancer screening and in whom the quality of bowel preparation was scored during the colonoscopy were recorded prospectively. The European Health Literacy Survey Questionnaire (HLS-EU-Q47) was used to evaluate HL prior to the colonoscopy, and the Boston bowel preparation scale was used to evaluate the quality of the bowel preparation during the colonoscopy. The demographic characteristics of the patients, the presence of comorbidities, socioeconomic characteristics (marital status, income level, and educational level), HLS-EU-Q47 questionnaire, and Boston bowel preparation scale scores were recorded and evaluated.

Results: A significant linear relationship was identified between the general HL index score, the cleanliness of the colonic segments (right, transverse, and left colon) and the total Boston bowel preparation scale score (p=0.013, p=0.010, p=0.008, p=0.001, respectively). In a HL subgroup analysis, a significant linear relationship was noted between disease prevention and health promotion index, the cleanliness of the colonic segments (right, transverse, and left colon), and the total Boston bowel preparation scale score. It was observed that an increase in the health care index resulted in an increase in the cleanliness of the relevant colonic segments and the total Boston bowel preparation scale score. No relationship was found between the right, transverse, and left colon and the total Boston bowel preparation scale scores and gender, age, Body Mass Index (BMI), comorbidity, marital status, level of income, or educational level.

Conclusion: The level of HL affects the quality of colonoscopy bowel preparations.
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http://dx.doi.org/10.5152/tjg.2020.19529DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759226PMC
November 2020

Change in Postoperative Opioid Prescribing Patterns for Oculoplastic and Orbital Procedures Associated With State Opioid Legislation.

JAMA Ophthalmol 2021 02;139(2):157-162

Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor.

Importance: Understanding whether statewide legislation, such as the Michigan Opioid Laws, is associated with reduction in postoperative opioid prescriptions is informative in guiding future legislation.

Objective: To identify changes in opioid prescribing patterns for oculoplastic and orbital procedures associated with the enactment of the Michigan Opioid Laws in 2017 and 2018.

Design, Setting, And Participants: This cross-sectional study included 3781 patients who underwent any of 10 common oculoplastic and orbital procedures between June 1, 2016, and November 30, 2019, at a tertiary care institution.

Exposures: From 2017 to 2018, Michigan enacted a series of laws to address the state's worsening opioid epidemic. Two major components of this legislation enacted on June 1, 2018, required prescribers to review a report of patients' opioid use history and obtain signed consent after educating patients on the use and disposal of opioids prior to prescribing.

Main Outcomes And Measures: Demographic information, type of surgery, type and amount of opioid prescriptions, and morphine milligram equivalent (MME) were analyzed. MME was calculated as the product of dose, quantity, and opioid-specific conversion factor for each prescription. Linear interpolation spline regression was used to evaluate the association of prescription MME with time.

Results: Of 3781 patients, 1614 (42.7%) were male. The mean (SD) age at the time of surgery was 63.3 (16.6) years. Of 2026 patients undergoing surgery before June 1, 2018, 1782 (88.0%) were prescribed postoperative opioids; of 1755 patients undergoing surgery after June 1, 2018, 878 (50.0%) were prescribed postoperative opioids (P < .001). There was no difference in age, sex, race/ethnicity, surgery type, or opioids prescribed between these 2 cohorts. Linear interpolation spline regression showed a decrease of 26.025 MMEs (equivalent to a 36.2% reduction of mean MME) between June 1, 2017, and September 30, 2018 (β, -1.735; 95% CI, -0.088 to -0.024; P < .001), stabilizing at a persistently reduced rate of MME prescribed through the end of the study period (October 1, 2018, to November 30, 2019; β, -0.005; 95% CI, -0.039 to 0.016; P = .42). Changes in MME in the 12 months before or 12 months after the period of legislation enactment were not identified.

Conclusions And Relevance: In this cross-sectional study, reduction in opioid prescriptions for oculoplastic and orbital procedures was observed during the enactment period of the Michigan Opioid Laws and appeared to be sustained through the end of the study period. Similar statewide or national legislations aimed at increasing prescriber awareness and patient education on opioid use may help curtail the prescription opioid epidemic.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.5446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729578PMC
February 2021

Penetration of Carbon Nanotubes into the Retinoblastoma Tumor after Intravitreal Injection in LH T Transgenic Mice Reti-noblastoma Model.

J Ophthalmic Vis Res 2020 Oct-Dec;15(4):446-452. Epub 2020 Oct 25.

Electrical Engineering and Computer Science, University of Michigan Ann Arbor, MI, USA.

Purpose: To evaluate the penetration of carbon nanotubes (CNTs) throughout retinoblastoma in a transgenic mice model.

Methods: CNTs functionalized with fluorescein isothiocyanate and targeting ligands biotin (CTN-FITC-Bio, 0.5mg/ml), or folic acid (CNT-FITC-FA, 0.5mg/ml) were injected into the vitreous of one eye of LH T transgenic mice. Other eye did not receive any injection and was used as control. Three mice were sacrificed at days 1, 2, and 3. Eyes were enucleated and stained with 4,6-diamidino-2-phenylindole. The sections were imaged by fluorescent microscope. The images were transformed into grey-scale in MATLAB for intensity analysis. Background intensity was normalized by marking squares outside the eyeball and using the mean intensity of these squares. Fluorescent intensity (FI) for each image was measured by calculating the intensity of a same-sized square within retinoblastoma.

Results: Nine eyes of nine mice were included in each CNT-FITC-Bio and CNT-FITC-FA groups. The mean FI in CNT-FITC-Bio was 52.08 6.33, 53.62 9.00, and 65.54 5.14 in days 1, 2, and 3, respectively. The mean FI in CNT-FITC-FA was 50.28 7.37, 59.21 6.43, and 58.38 2.32 on days 1, 2, and 3, respectively. FI was significantly higher in eyes injected with CNT-FITC-Bio and CNT-FITC-FA compared to the control eyes ( = 0.02). There was no difference in FI between eyes with CNT-FITC-Bio and CNT-FITC-FA, and FI remained stable on days 1-3 in CNT-FITC-Bio, CNT-FITC-FA, and control eyes ( 0.05).

Conclusion: We observed higher FI in eyes with CNT-FITC-Bio and CNT-FITC-FA compared to control eyes, showing penetration of CNTs throughout retinoblastoma. CNTs can be a carrier candidate for imaging or therapeutic purposes in retinoblastoma.
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http://dx.doi.org/10.18502/jovr.v15i4.7778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591833PMC
October 2020

Immunotherapy for Conjunctival Squamous Cell Carcinoma with Orbital Extension.

Ophthalmology 2021 05 25;128(5):801-804. Epub 2020 Sep 25.

Roger Cancer Center, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.ophtha.2020.09.027DOI Listing
May 2021

Effect of health literacy on help-seeking behavior: A comparison of patients accepting surgery and refusing surgery for urinary incontinence.

J Gynecol Obstet Hum Reprod 2021 Apr 11;50(4):101908. Epub 2020 Sep 11.

University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Department of Family Medicine, Turkey. Electronic address:

Objective(s): To compare the health literacy (HL) of the adult females with SUI complaints in terms of their acceptance or non-acceptance of surgery.

Methods: In this cohort study, the European Health Literacy Survey Questionnaire (HLS-EU- Q47) scores as a measure of health literacy were compared among the two groups of patients who accepted to undergo surgery for SUI and the ones who did not. Demographic features, weight and BMI values, comorbidity, menopausal status, duration and type of UI, socioeconomic characteristics (marital status, educational level, level of income) and HLS-EU- Q47 survey results of the two groups were compared. We also investigated the reasons regarding the acceptance or refusal of SUI surgery.

Results: Among the patients who were offered surgery 474% accepted to undergo operation. Total HLS-EU-Q47 score was 30.04 in the group of patients who accepted surgery and 23.46 in the group who refused surgery. The patients that refused surgery had more often insufficient health literacy level (p=0.001). An excellent health literacy level was higher for patients who agreed to anti-incontinence surgery (p=0.021).

Conclusions: Health literacy score of patients with urinary incontinence (UI) who refused surgery was lower than those who accepted surgery. Acceptance of surgery may be increased by providing more understandable and clear information, especially for women with lower HL levels.
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http://dx.doi.org/10.1016/j.jogoh.2020.101908DOI Listing
April 2021

Comparison of the effects of trospium and solifenacin on intraocular pressure and tear secretion in patients with overactive bladder.

Int Urogynecol J 2021 Jan 4;32(1):173-178. Epub 2020 Aug 4.

University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Family Medicine, Bursa, Turkey.

Introduction And Hypothesis: Comparison of the effects of trospium and solifenacin used for the treatment of overactive bladder (OAB) on intraocular pressure (IOP) and tear secretion.

Methods: This study was planned as a prospective study and was conducted at a single center between October 2014 and April 2016. OAB patients were included in the study following an ophthalmic examination, IOP measurement with an applanation tonometer, and tear secretion measurement with the Schirmer I test in the ophthalmology outpatient department. The patients were started with trospium 30 mg oral bid or solifenacin 5 mg oral qd. They were then followed up at the 4th and 12th weeks.

Results: A total of 225 OAB patients with a mean age of 47.80 (18-75) years were evaluated. The mean age was 47.41 ± 12.65 years in the trospium group (n = 104) and 48.14 ± 11.82 years in the solifenacin group (n = 121) with no statistically significant difference. When the two medications were compared, no statistically significant difference was observed at the 4th and 12th weeks in terms of IOP (p = 0.988, p = 0.822) and dry eye (p = 0.764, p = 0.581).

Conclusions: No statistically significant difference was observed between trospium and solifenacin in terms of their effects on IOP and tear secretion in OAB patients. We therefore concluded that the effects of trospium and solifenacin on IOP and tear secretion changes were similar in OAB patients without comorbidities.
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http://dx.doi.org/10.1007/s00192-020-04473-4DOI Listing
January 2021

Retinal Whitening After Lung Transplant for Cystic Fibrosis.

JAMA Ophthalmol 2020 09;138(9):994-995

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1001/jamaophthalmol.2020.1306DOI Listing
September 2020

An adolescent with uveal melanoma and tumor predisposition syndrome.

JAAD Case Rep 2020 Jun 25;6(6):563-566. Epub 2020 Apr 25.

Department of Dermatology, Michigan Medicine, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.jdcr.2020.04.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265053PMC
June 2020

Geriatric giants in women over 65 years living in a rural area in Turkey.

J Women Aging 2021 Nov-Dec;33(6):676-682. Epub 2020 Jun 6.

Urology, Bursa Yuksek Ihtisas Trainig and Research Hospital, Bursa, Turkey.

The aim of this study was to determine the prevalence of fall tendency, urinary incontinence, and dementia in women over 65 years of age living in rural areas of Turkey. The research was a descriptive study. Mini-Mental tests, The International Consultation of Incontinence Questionnaire (ICIQ) short forms, and Falls Behavioral Scales for the elderly were used. Urinary incontinence prevalence in women over 65 years of age living in rural areas of Bursa was 51%. Dementia frequency was calculated as 56%. A reverse and significant relationship was detected between Mini-Mental Scale and ICIQ scale scores ( = -0.12; = .017). The Falls Behavioral Scale score was higher in the group with incontinence. The conclusion reached was that urinary incontinence and dementia are frequent among older women living in rural areas in Turkey. As diseases known as geriatric giants are associated with each other, treatment of one of them may bring protection from another negative situation.
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http://dx.doi.org/10.1080/08952841.2020.1763890DOI Listing
November 2021
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