ISSN: 2149-2247 | E-ISSN: 2149-2549
ERCİYES MEDICAL JOURNAL - Erciyes Med J: 43 (1)
Volume: 43  Issue: 1 - 2021
EDITORIAL COMMENTS
1.COVID-19 Outbreak and Impact on Food Safety
Elisavet Stavropoulou, Eugenia Bezirtzoglou
doi: 10.14744/etd.2020.58966  Pages 1 - 2
Abstract | Full Text PDF

INVITED REVIEW
2.Efficacy and Safety of Myrtol® Standardized in the Treatment of Acute and Chronic Rhinosinusitis: A Review of Literature
Aleksandar Peric, Tanja Kosak Soklic, Aleksandra Aleksic, Gabriela Kopacheva-Barsova, Aneta V. Peric
doi: 10.14744/etd.2020.34467  Pages 3 - 8
The clinical pattern of rhinosinusitis is based on key symptoms, such as nasal obstruction/congestion, nasal secretion with postnasal discharge, facial pain with pressure, and impaired sense of smell. Acute rhinosinusitis is a viral infection commonly caused by impaired paranasal sinus aeration and drainage and can progress to bacterial superinfection. Chronic rhinosinusitis is an inflammatory disease of the sinonasal mucosa with symptoms persisting for more than 12 weeks. This paper aimed to summarize and update the literature related to the use of herbal product Myrtol® standardized in the treatment of acute and chronic rhinosinusitis. Earlier investigations have demonstrated that Myrtol® standardized has strong secretolytic, secretomotoric, anti-inflammatory, antioxidative, and antimicrobial effects. Therefore, this study reviewed randomized studies related to its use in the treatment of upper-airway inflammations and discussed the mechanisms of action of this herbal drug on infected nasal and paranasal sinuses mucosa.

REVIEW
3.The role of macrophage in atherosclerosis: An overview
İbrahim Halil Damar, Recep Eroz
doi: 10.14744/etd.2020.53077  Pages 9 - 12
Knowlege of the mechanism of atherosclerosis in chronic and inflammatory diseases is important in health care management. According to the World Health Organization, approximately 17.9 million people die from atherosclerosis annually. Macrophages played a major role in the immune response and pathophysiology of atherosclerosis. This review presents the role of macrophage in the development of atherosclerosis.

ORIGINAL ARTICLE
4.Impaired Renal Function in Outpatients with Acute Carbon Monoxide Poisoning
Nahide Ekici Gunay, Aykut Kale, Nurullah Günay
doi: 10.14744/etd.2020.52993  Pages 13 - 19
Objective: The study aims to investigate the incidence of early stage kidney disease in outpatients with acute carbon monoxide poisoning (CMP) and to assess whether the Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) values of these patients had any impact on the time taken for their discharge.
Materials and Methods: This retrospective case–control study consisted of a total of 94 patients (47 patients with carbon monoxide poisoning induced by exposure to incompletely burned coal, and 47 age-and sex-matched controls). Patient details including age, CKD-EPI value, hemoglobin, carboxyhemoglobin (COHb), lactate, pH, SaO2, pO2 pCO2, BE, HCO3, glucose, AST, ALT, amylase, ALP, BUN, creatinine, Na, K, Cl, CK, CK-MB, troponin, uric acid levels and duration of follow-up were recorded. The post-hoc power analysis was calculated using G*Power 3.1.9.2 based on the difference between the two means by Wilcoxon–Mann–Whitney test. A Kaplan–Meier survival curve was plotted and test of equality of survival distributions for the different levels of CKD-EPI was compared.
Results: The mean age and mean COHb values of the study group were 37.24±12.91 and 21.45±9.89, respectively. The CKD-EPI values were lower in patients belonging to the CMP group (101.39±19.53) compared to the control group (114.92±14.81) (p=0.017), 92% power level, d=0.781, 95% confidence intervals (CI) on the difference between means (-23.01/-4.04). The duration of follow-up of patients with CMP was 29.04±9.7 hours. There was a significant relationship between the follow-up duration of patients with CMP in the emergency department and their CKD-EPI levels (Log-rank/Mantel–Cox, p<0.001).
Conclusion: CKD-EPI-values are reduced as a result of impaired renal function in outpatients with CMP in the early stages. Thus, long-term nephrology follow-up should be performed in outpatients diagnosed with CMP. Further investigations may be required to rule out possible chronic kidney disease (CKD) associated with impaired renal function induced by acute CMP.

5.Serum Level of ADAMTS4 and ADAMTS8 in Patients with Psoriatic Arthritis
Irmak Icen Taskin, Sevgi Irtegun Kandemir, Kemal Nas, Abdullah Zübeyir Dağlı
doi: 10.14744/etd.2020.65625  Pages 20 - 25
Objective: Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis. A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) is a large family of proteoglycanase enzymes that show proteolytic activity. The expression levels of ADAMTS proteases in osteoarthritis and rheumatoid arthritis are upregulated. However, their expression levels in PsA patients have not been examined yet. The aim of this study was to determine the serum levels of ADAMTS4 and ADAMTS8 in PsA patients.
Materials and Methods: This was a case-control study and enrolled 40 PsA patients and 40 individuals as controls. Serum levels of ADAMTS4 and ADAMTS8 were examined by the enzyme-linked immunosorbent assay (ELISA). The relationship between ADAMTS8 levels and demographic and clinical features of PsA patients were analyzed.
Results: The results of this study showed that the ADAMTS8 level was significantly elevated in the serum of PsA patients (160.9±49.79 pg/mL) compared to the control groups (<15.6 pg/mL). An association (r=0.32, p<0.05) was detected between age and serum level of ADAMTS8. However, the level of the ADAMTS4 in many subjects was under the detectable range.
Conclusion: Our results conclude that a relationship exists between ADAMTS8 and PsA, but further investigations are required to establish the function of ADAMTS8 proteases in PsA.

6.Effect of Supine and Prone Flexion Positions on Heart Rate, Oxygen Saturation, and Pain Score of Preterm Infants
Sabiha Çağlayan, Duygu Gözen
doi: 10.14744/etd.2020.82195  Pages 26 - 30
Objective: The study aimed to determine the effect of supine and prone flexion positions on heart rate, oxygen saturation, and pain level of preterm infants in the neonatal intensive care unit.
Materials and Methods: This study consisted of 46 preterm infants in a university hospital between February and November 2014. The effects of two different positions on heart rate, oxygen saturation, and pain were assessed by giving both positions to each infant for 2 h.
Results: Heart rate increased in the prone flexion position, but oxygen saturation was similar in both positions. In addition, pain score decreased on the second hour in prone position.
Conclusion: The results showed that infants were influenced more by environmental stimuli in the supine flexion position.

7.Overlooked Prophylaxis of Hepatitis B in Patients Undergoing Hematopoietic Stem Cell Transplantation
Zeynep Türe, Gamze Kalin Unuvar, Hüseyin Nadir Kahveci, Muzaffer Keklik, Ayşegul Ulu Kilic
doi: 10.14744/etd.2020.36786  Pages 31 - 36
Objective: The reactivation rate of dormant hepatitis B virus (HBV) in the liver is between 4.1% and 41.5% in immune-compromised patients. The disappearance of hepatitis B surface antibody (anti-HBs) can be an alarm for hepatitis B reactivation. In this study, the changes in serological status, reactivation rates, and antiviral prophylaxis rates were evaluated.
Materials and Methods: A retrospective study was conducted involving patients who were followed up at Erciyes University HSCT Center between January 2018 and July 2019. The demographic data, type of hematological disease, pre- and post-transplant status of HBV, presence of antiviral prophylaxis, and frequency of hepatitis B flare were evaluated.
Results: One hundred and seven patients were included in this study. The median follow-up duration was 18 months. New chemotherapy protocols were initiated in 36 patients due to progression and in 23 patients with a diagnosis of graft-versus-host disease. Anti-HBs levels decreased in 60% of the patients, and anti-HBs levels decreased to below the protective level in 13% of the patients. Among the 107 patients, 38 had resolved hepatitis B infection before transplantation, and 20 and four of 18 patients (22%) who did not receive antiviral prophylaxis developed HBV seroconversion and hepatitis B flare. The median levels of anti-HBs titers after transplantation were 167 IU/L and 15 IU/L in groups that received and did not receive antiviral prophylaxis, respectively (p=0.028).
Conclusion: Antiviral prophylaxis should be administered in patients positive for hepatitis B core antibody before hematopoietic stem-cell transplantation. Measuring HBV serological parameters at regular intervals is essential in the high-risk group.

8.Relationship Between Endocrinopathies and Ferritin Levels in Adult Turkish Patients with Beta Thalassemia Major: A Single-Center Experience
Gülsüm Akgun Çağlıyan, Güzin Fidan Yaylalı, Nur Soyer, Sibel Hacıoğlu, Ömer Çağlıyan, Nil Güler
doi: 10.14744/etd.2020.33427  Pages 37 - 42
Objective: Despite regular transfusions and iron-chelation therapies, endocrine complications still remain an important cause of morbidity in patients with beta thalassemia major (BTM). We aimed to evaluate the relationship between endocrine complications and serum ferritin levels in adult patients with BTM.
Materials and Methods: The endocrine test results of adult patients with BTM were retrospectively reviewed. Normality testing was performed using the Shapiro–Wilk test. For the analysis, we used an independent samples t-test when parametric test assumptions were met; otherwise we used Mann–Whitney U test. A p value of <0.05 was considered statistically significant.
Results: A total of 66 adult patients with BTM. (female: 56.1%, male: 43.9%, mean age: 25.8±6.6 years) were evaluated. The mean ferritin level was 1504.9±861 ng/ml (range 304–5464 ng/ml). Of the patients, 60.6% had endocrinopathy. The rates of hypogonadism was 51.5%, hypothyroidism was 16.7% (subclinical hypothyroidism: 13.6%, central hypothyroidism: 3.03%), hypoparathyroidism was 10.6%, diabetes mellitus was 7.6%, vitamin D insufficiency was 40.9%, vitamin D deficiency was 33.3%, low bone mass was 56.1%, and that of low IGF-1 was 57.6%. We found a significant relationship between ferritin levels and the presence of hypogonadism, low bone mass, and low IGF-1 levels (p<0.001). Patients used higher doses of deferasirox due to iron overload (p<0.001). Patients needed higher deferasirox doses to decrease ferritin levels.
Conclusion: Among adult patients with BTM, endocrinopathies were prevalent in patients with elevated ferritin levels. Patients with BTM should undergo regular testing for endocrine disorders, and ferritin levels must be kept under control.

9.Comparison Effect of Local Subcutaneous Tramadol and Methadone in Post-laparotomy Pain Control
Majid Montazer, Mostafa Hojjati, Seyed Ehsan Mousavi Toomatari
doi: 10.14744/etd.2020.53503  Pages 43 - 46
Introduction: Management of postoperative pain is important part of surgical care. Methadone and tramadol have been used for pain relief after surgery. In this study, we evaluated the effects of subcutaneous injection of methadone and tramadol before skin suture on postoperative pain following laparotomy.
Methods: In this Double-blinded randomized clinical trial, sixty patients undergoing major abdominal surgery were randomly allocated into two subcutaneous methadone or tramadol groups. Either tramadol 1.5 mg/kg or methadone 70 μg/kg, both diluted with normal saline to 10 cc were injected subcutaneously around the incision. Then patients’ pain severity one, 6, 12, 18, 24 hours after surgery was measured using visual analogue scale (VAS). Pethidine was injected if the patient requested for pain relief. The administered pethidine doses and pain VAS was compared between two groups.
Results: There was no significant difference in duration of hospital stay post-surgery between tramadol and methadone groups. Both drugs were effective in reducing pain in the first 12 hours with no significant difference between groups; afterwards the pain was aggravated. However, the pain VAS was significantly lower in tramadol group in 18 (3.13±0.93 vs. 4.30±0.95, p<0.001) and 24 hours (3.93±0.86 vs. 5.00±1.25, p<0.001). Tramadol group required significantly lower dose of pethidine (214.01±23.12 mg vs. 243.3±36.72 mg, p=0.01).
Conclusion: Subcutaneous administration of tramadol and methadone were both effective in relieving pain in the first 12 hours post-surgery, but after that the need for analgesics are increased. Tramadol seems more effective than methadone in pain control in the first day after surgery.

10.Effects of Attitudes of Patients with Epilepsy Towards Their Disease on Mental Health and Quality of Life
Tuğba Akyol, Sevgi Nehir
doi: 10.14744/etd.2020.95870  Pages 47 - 53
Objective: The study investigates the effects of attitudes displayed by patients with epilepsy toward their disease on their mental health and quality of life.
Materials and Methods: This descriptive cross-sectional study was conducted in the neurology outpatient clinic at Hafsa Sultan Hospital, Manisa Celal Bayar University between April 2015 and April 2016. The study sample comprised 182 patients. The study data were collected using the Personal Information Form for Patients with Epilepsy, Impact of Epilepsy Scale, Epilepsy Knowledge Scale, Epilepsy Attitude Scale, Short Form-36 (Quality of Life Scale), and Brief Symptom Inventory. In the analysis of the data, the t-test, ANOVA, Scheffé’s post-hoc test, and Pearson’s correlation coefficient were used.
Results: In the Epilepsy Attitude Scale, the participants obtained a mean score of 48.66±13.13, suggesting that they displayed negative attitudes toward epilepsy. In the subscales of the Short Form-36 (Quality of Life Scale), the participants’ scores were low. Of the participants with epilepsy, those with a significantly positive attitude toward epilepsy had a high quality of life perception. Psychological symptoms decreased in patients with epilepsy who have a positive attitude toward their disease.
Conclusion: The results of this study demonstrated that the participants’ “attitudes toward epilepsy” was significantly correlated to their “psychological symptoms and quality of life.” The fact that the negative attitudes of patients with epilepsy are related to their psychological symptoms and quality of life indicates the importance of recognizing and understanding patients’ attitudes toward their disease.

11.Clinical and Molecular Spectrum of Tuberous Sclerosis Complex Patients: Identification of Three Novel Mutations
Esra Işık, Hüseyin Onay, Tahir Atık, Aslı Ece Solmaz, Demet Terek, Sarenur Gökben, Hasan Tekgül, Ertürk Levent, Mehmet Kantar, Nilgün Kültürsay, Özgür Çoğulu, Ferda Özkınay
doi: 10.14744/etd.2020.49765  Pages 54 - 60
Objective: Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous syndrome. TSC arises from mutations in either TSC1, at 9q34, or TSC2, at 16p13.3. Skin lesions, such as hypomelanotic macules, facial angiofibromas, shagreen patches, and ungual fibromas, are frequently seen in these patients. The present study aims to investigate clinical manifestations, molecular findings and phenotype-genotype correlations in 17 patients with TSC.
Materials and Methods: TSC1 and TSC2 molecular analyses were performed on a next-generation sequencing platform (Illumina MiSeq). Variant interpretation was made in accordance with the American College of Medical Genetics 2015 recommendations.
Results: Four patients carried a heterozygous mutation in TSC1, while the remaining seven carried mutations in TSC2. Three novel variants in TSC2 were defined. Sequencing failed to detect a mutation in six patients. In only one of these patients, multiplex ligation-dependent probe amplification (MLPA®) could be performed, and a large deletion in the TSC1 gene was detected. A wide spectrum of phenotypic features was noted throughout the study group. Dermatological findings were observed in almost all patients.
Conclusion: In this study, in addition to the three novel mutations reported herein, the spectrum of TSC1 and TSC2 gene mutations and their phenotypes were reported.

12.Relationship Between Ventriculoperitoneal Shunt Obstruction and Infection in Pediatric Patients with Hydrocephalus
Ali Şahin, Abdulfettah Tumturk, Murat Çiftçi, Nimetullah Alper Durmus, Ahmet Küçük, Halil Ulutabanca, Ibrahim Suat Öktem
doi: 10.14744/etd.2020.25493  Pages 61 - 66
Objective: The most common ventriculoperitoneal shunt (VPS) complications in pediatric patients include shunt infections and obstructions. This study evaluated the relationship between shunt infection and obstruction in pediatric patients undergoing VPS placement for hydrocephalus at our clinic.
Materials and Methods: Altogether, 210 patients ≤16 years old who were diagnosed with hydrocephalus and who received VPS placement by the same surgeon between January 2012 and June 2017 were followed up for at least one year and were evaluated retrospectively. Patients’ clinical and laboratory findings were evaluated, and computed tomography and magnetic resonance imaging were performed. Pearson’s chi-squared and Fisher–Freeman–Halton tests were used for statistical data analysis.
Results: Among the 210 patients, shunt complications developed in 86; of these 86 patients, shunt infections, shunt obstructions, and other complications developed in 41, 53 (non-infection-related: 31 and infection-related: 22), and 14 patients, respectively. The infection rate in patients in whom VPS placement was performed from the frontal region was lower than those patients in whom it was performed from the occipitoparietal region. The obstruction rate was significantly higher in patients with shunt infection than in those without. Obstruction occurred in one-third of the patients with Staphylococcus epidermidis infection among patients with shunt infection.
Conclusion: The obstruction rate in patients with shunt infection was three times higher than those without. Considering that shunt infection may accompany obstruction, making the decisions regarding the treatment method for patients with shunt obstruction is appropriate, after determining whether a shunt infection exists.

13.Evaluation of Proper Inhaler Use in Children Acute Asthma Admitted to the Emergency Department: A Single Center Cross-sectional Study
Ayşegül Aslan Çınar, Pınar Altınkaynak, Esen Besli, Mehmet Özdemir, Mustafa Arga
doi: 10.14744/etd.2020.74050  Pages 67 - 74
Objective: This study aimed to determine the accuracy of the inhaler technique used among asthmatic patients admitted to the emergency department (ED) due to acute asthma attack.
Materials and Methods: A total of 303 patients with childhood asthma were enrolled in this study. A survey consisting of 22 questions was conducted on patients and/or their parents during ED visits. Additionally, multiple logistic regression analysis was performed to determine the independent predictors affect the use of rescue inhaler treatment.
Results: In the study, although 258 patients were prescribed a rescue inhaler asthma treatment, only 212 (85.1%) used this treatment before the ED visits. Only 193 (78.4%) patients properly used an inhaler device. A total of 61 (23.7%) patients knew that they had run out of inhalers according to the number of doses recommended in the prospectus. According to multiple analysis, a close regular follow-up by the primary physician, by either allergist/immunologist or chest disease specialist, and the administration of inhaler by the parents were identified as independent risk factors for the use of rescue inhaler therapy.
Conclusion: Only three-quarters of the patients were found to use rescue inhaler therapy correctly. The improper use of inhaler device was more common in adolescents who administered the drug themselves. Patients who were followed-up by either allergist/immunologist or chest disease specialist had a two times higher chance of using rescue inhaler therapy in this study.

14.Relationship Between the Flow-Mediated Dilatation of the Human Brachial Artery and Blood Biomarkers Related to the Endothelial Function in Cardiovascular Diseases
Suzan Emel Usanmaz, Inci Asli Atar, Ayşen Aksöyek, Muharrem Tola, Emre Kubat, Tugba Kayhan Altuner, Hüseyin Bozbaş, Utkan Sevuk, Mehmet Emin Korkmaz, Emine Demirel-Yilmaz
doi: 10.14744/etd.2020.90592  Pages 75 - 82
Objective: Endothelial dysfunction plays an important role in the development of heart diseases. Although several markers have been examined, a definitive biomarker for monitoring endothelial function has not yet been established. The flow-mediated dilatation (FMD) of the brachial artery enables non-invasive assessment of endothelial function. This study investigated plasma levels of nitric oxide (NO), asymmetric dimethylarginine (ADMA), total antioxidant capacity (TAC), and hydrogen sulfide (H2S) as biomarkers of endothelial function. This study aimed to investigate any correlation between FMD and these blood biomarkers in patients with diabetes mellitus (DM), prediabetes (preDM), coronary artery disease (CAD), and valvular heart disease (VD).
Materials and Methods: Prospective evaluation was made within five groups of patients with preDM, DM, CAD, VD, and healthy controls. The FMD of the brachial artery was examined using Doppler imaging, and biomarker levels in plasma were measured by spectrophotometry.
Results: The FMD of the VD group was significantly higher than that of DM and CAD groups. Plasma NO levels of CAD and VD groups were significantly lower than those of the control group. ADMA levels were lower in the CAD group. TAC and H2S levels were comparable in all groups. The FMD of the brachial artery was negatively correlated with plasma NO and cholesterol levels in all groups.
Conclusion: These results suggested that the correlation of FMD with blood biomarkers related to endothelial function was altered in cardiovascular diseases and would be affected by the patient’s clinical state and treatment.

15.Predictive Value of Thiol–Disulfide Homeostasis and Ischemia-Modified Albumin on Survival in Patients with Sepsis
Bilgin Bahadır Başgöz, Ramazan Acar, Musa Baris Aykan, Salim Neşelioğlu, Özcan Erel, Levent Yamanel, Ilker Taşçı
doi: 10.14744/etd.2020.05902  Pages 83 - 89
Objective: Sepsis is a dysregulated systemic inflammatory and oxidative response to infection. Thiol–disulfide homeostasis (TDH) has a crucial role in the protection from oxidative stress and is a reliable indicator of oxidative stress. Furthermore, ischemia-modified albumin (IMA) is an indicator of oxidative-stress-related tissue damage. In this study, we determined the predictive value of TDH and IMA on 28-day mortality in patients undergoing sepsis.
Materials and Methods: We collected blood samples from adult patients undergoing sepsis at the time of admission to the intensive care unit to determine TDH and IMA levels. Concurrently, we calculated Sequential Organ Failure Assessment (SOFA) scores to weigh the severity of sepsis. Moreover, we followed up the patients for 28-day intra-hospital mortality. We statistically analyzed the study parameters of the patients in both the survivor and non-survivor groups.
Results: Forty-six patients with sepsis were enrolled. Among them, 27 survived at the end of the 28-day follow-up period. The mean age of the patients was 73.07±13.87 years, and 43.5% of them were female. The mean SOFA score was significantly higher in the non-survivor group (p<0.05). However, no significant differences in the total thiol, native thiol, disulfide, and IMA levels at baseline were observed between the survivor and non-survivor groups (p>0.05 for all). Receiver operator characteristics (ROC) and area under the curve (AUC) analysis revealed that IMA and thiol parameters had no predictive power on the survival of patients with sepsis.
Conclusion: This study showed that baseline TDH parameters and IMA levels were not significantly different between survivors and non-survivors of sepsis and were not related to the prediction of mortality.

CASE REPORT
16.Hemangioma Turned Into a Gigantic Tongue: A Rare Case of Maffucci Syndrome
Kevser Peker
doi: 10.14744/etd.2020.28458  Pages 90 - 92
Background: This is a rare case of Maffucci syndrome who underwent orthopedic surgery owing to enchondroma and who had hemangiomas in the tongue tip.
Case Report: After anesthesia induction, a 60-year-old male patient was intubated with direct laryngoscopy without any trauma to the hemangioma. However, before extubation, the edema in the patient’s tongue was observed to slightly increase. After the endotracheal tube was removed, the patient had stridor, the airway was obstructed, the patient could not tolerate this condition, and he was subsequently reintubated. It was observed that the hemangioma in the tongue tip was dilated. The patient was followed up in the intensive care unit for 1 day and was extubated the following day with the reduction of hemangioma and tissue edema.
Conclusion: The examination of hemangiomas, especially in the upper airway, requires careful attention from an anesthetic point of view.

17.An H-Shaped Duplicated Gallbladder Presenting with Acute Cholecystitis: A Case Report
Ibrahim Yılmaz, Mustafa Taner Bostancı, Mehmet Saydam, Ahmet Seki
doi: 10.14744/etd.2020.57255  Pages 93 - 95
Background: Gallbladder (GB) duplication is a rare congenital biliary anomaly, which can increase iatrogenic biliary injuries during surgery. We report a case of duplicated GB presenting with acute cholecystitis in order to draw attention to its diagnosis and treatment.
Case Report: A 57-year-old male patient with complaints of dyspepsia was diagnosed by ultrasound with duplicated GB containing gallstones, but the patient did not consent to undergo treatment. Three months later, the patient developed acute cholecystitis and obstructive jaundice, and was referred to our hospital. MR cholangiography showed an H-shaped duplicated gallbladder with gallstones in the common bile duct, and then ERCP was performed. The laparoscopic view could not completely identify the anatomy of the GBs and cystic ducts; therefore, a conventional cholecystectomy was performed.
Conclusion: Laparoscopic cholecystectomy for H-shaped duplicated GB cases with cholecystitis may be challenging due to the duplicated cystic canals and GB inflammation. Anatomic variations should be identified preoperatively with proper imaging modalities. Laparoscopic cholecystectomy should be primarily performed, as well as conventional cholecystectomy if required, to prevent biliary tract injuries.

IMAGE
18.An Unexpected Cause of Inflammatory Low Back Pain: Osteitis Condensans Ilii
Sadettin Uslu
doi: 10.14744/etd.2020.51437  Pages 96 - 97
Abstract | Full Text PDF

LETTER TO THE EDITOR
19.Chronic Fatigue Syndrome After COVID-19 Infection: A Call for Action
Pradyumna Pan, Ritika Pan
doi: 10.14744/etd.2020.06767  Pages 98 - 99
Abstract | Full Text PDF

HISTORY OF MEDICINE - REVIEW
20.Vaccination of the Ethnic Greeks (Rums) Against Smallpox in the Ottoman Empire: Emmanuel Timonis and Jacobus Pylarinos as Precursors of Edward Jenner
Theodoros Kyrkoudis, Gregory Tsoucalas, Vasilios Thomaidis, Ioannis Bakirtzis, Eleni Nalbanti, Alexandros Polychronidis, Aliki Fiska
doi: 10.14744/etd.2020.82856  Pages 100 - 106
This historical review examined the onset of the vaccination method during the Ottoman Empire. Inoculation was performed in the regions of Thessaly, Macedonia, and Thrace using folk medicine as a measure against the spread of smallpox/variola infection. Greek physicians Emmanuel Timonis (1669–1720) and Jacobus Pylarinos (1659–1718) as well as several other Ottoman scientists of the Greek or Turkish descent pioneered the use and dissemination of variolation and the development of vaccination before or concurrently with Edward Jenner (1749–1823). During the 19th century in the Adrianople (Edirne) region and much earlier in Constantinople (İstanbul), vaccination programs used to be implemented as evidenced by various certificates distributed at that time. Ottoman vaccination documents from the early 20th century and the letter of Lady Mary Wortley Montagu (1689–1762), dated 1719, have been analyzed, which confirms the extensive use of the vaccination method. Smallpox was the first disease to have been treated with vaccination method. The difference between the Greek and Ottoman physicians and Edward Jenner lies in the fact that while the Greek and Ottoman physicians removed fluid from pustules of an infected person to perform inoculation, Edward Jenner removed fluid from pustules of infected cows, which is why Edward Jenner’s method was coined vaccination (derived from the Latin word “vacca” meaning “cow”). Further, Turkish physicians Mustafa Behçet Efendi (1774–1834) and Sanizade Mehmed Ataullah Efendi (1771–1826) recommended the variolation method. It thus appears that the Ottomans provided care to all ethnicities of their Empire. Vaccines were initially used against smallpox, but the immunization program was eventually extended to other diseases.

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