Any manipulation or resection procedures during surgery of neural system or its surrounding structures carries a high risk of causing damage to the neural tissue. Existing intraoperative imaging tools provide only information about anatomic situation. Because of this insufficiency, both physicians and patients are displeased with additional neural deficits. Using intraoperative neurophysiological monitoring (IONM) that evaluate neurological function simultaneously is very important. It is also used in other surgical operations. In our article, we report importance and advantages of IONM in neurosurgical operations

Kulak burun boðaz doktorlarýnýn büyük kýsmý parotis cerrahisini uygulamaktadýrlar. Fasiyal sinirin anatomisini anlamak ve titiz bir cerrahi teknik, bu prosedür için gereklidir. Ancak en deneyimli ellerde dahi komplikasyonlar olmaktadýr. Fasiyal sinir monitörizasyonu, fasiyal sinirin fonksiyonel olarak korunmasýna yardýmcý olmak için parotis cerrahisi sýrasýnda cerrah için kullanýlabilir yardýmcý bir yöntemdir. Bu derlemede parotis cerrahisi sýrasýndaki hedefleri, uygulamalarý, tekniði ve elektrofizyolojik fasiyal sinir monitörizasyonu kullanýmýnýn yararlarýndan bahsedilmektedir.

Tiroit cerrahisi sonrasý oluþan sesle ilgili problemler sýk ve en önemli komplikasyonlardandýr. Cerrahi sonrasý hastanýn ses ve solunum problemlerini minimalize edebilmek için hem reküren laringeal sinirin (RLS) hem de süperior laringeal sinirin eksternal dalýnýn (SLSE) korunmasý gerekir. Ýntraoperatif nöromonitorizasyon (ÝONM) sinirin gözle görülmesine ek olarak ameliyat sýrasýnda sinirin motor fonksiyonlarýnýn dinamik olarak deðerlendirilmesi temeline dayanan bir yöntemdir. Tiroit cerrahisinde ÝONM 50 yýl önce kullanýlmaya baþlanmýþ ve yüzey elektrotlu endotrakeal tüp ile ÝONM; amaca uygunluk, basitlik, noninvazif olma ve güvenlilik gibi nedenlerle standart uygulanan yöntem haline gelmiþ olup, günümüzde tiroit cerrahisinde bu yöntem kullanýlmaktadýr. Tiroit cerrahisinde RLS ve SLSE için ÝONM kullanýmý giderek artmaktadýr. ÝONM’nin uygun kullanýmý için hem anestezist hem cerrah için deneyim ve standardizasyonu þarttýr. Bu baðlamda hem cerrahlarýn hem de anestezistler için öðrenme eðrisi yaklaþýk 50-100 arasý olgudur. ÝONM hem RLS hem SLSE’nin bulunmasýnda ve fonksiyonel olarak deðerlendirilmesinde önemli katký saðlar. RLS monitorizasyonu monitorizasyon probu ile aralýklý veya vagusa uygulanan prob yardýmý ile sürekli olarak uygulanabilir. RLS monitorizasyonunun standardizasyonu; preoperatif laringoskopi ile vokal kord muayenesi (L1), RLS diseksiyonu öncesi ayný taraf vagustan uyarý alýnmasý (V1), RLS’nin trakeaozefageal olukta ilk bulunduðu noktada uyarýlmasý (R1), diseksiyon bittikten sonra RLS’nin ortaya konduðu en proksimal noktasýndan uyarýlmasý (R2), cerrahi alanda kanama kontrolü tamamlandýktan sonra vagusun uyarýlmasý (V2), postoperatif laringoskopi ile vokal kord muayenesini (L2) içerir. V2 postoperatif vokal kord fonksiyonunu öngörmede en uygun testtir. RLS aralýklý ÝONM’sinde sadece sinirin probla uyarýldýðý an ve sinirin uyarýldýðý nokta distalinin fonksiyonu hakkýnda bilgi verir. Sürekli ÝONM ise RLS’nin vagustan ayrýlmadan önce boyunda vagusa uygulanan probla yapýlan devamlý uyarý sayesinde cerraha tiroidi diseke ederken RLS fonksiyonunun sürekli takip edilmesini saðlar. SLSE monitorizasyonunda primer olarak ameliyat sahasýnda bulunan ve SLSE’nin motor siniri olduðu krikotiroid kasýn kasýlmasý deðerlendirilir. ÝONM hem RLS hem SLSE’nin bulunmasýnda ve fonksiyonel olarak deðerlendirilmesinde önemli katký saðlamasý ile birlikte tiroidektomiye birçok açýdan katký saðlayan ve tiroidektominin standartlarýný arttýran bir yöntemdir.

The recommended management of febrile neonates, in first 28 days of life is controversial. Given that the overall prevalence of serious bacterial infection is higher in the neonate, most experts would advocate for a full sepsis evaluation, and hospitalization for giving antibiotics. In recent years, opinions have been raised regarding the follow-up without hospitalization and antibiotics or followup even without hospitalization in febrile newborn infants. In our review the evidence for diagnostic accuracy of screening methods for identification of serious bacterial infection in febrile neonates will be evaluated.

Objective: We aimed to evaluate the necessity and the worthiness of postoperative vocal cord examination in cases with no loss of signal during intraoperative nerve monitoring (IONM) in thyroid and parathyroid surgery.
Material and Methods: We retrospectively evaluated cases that had no loss of signal during intraoperative nerve monitoring in cases who underwent thyroid and parathyroid surgery in our endocrine surgery unit, between January 2014 – January 2017.
Results: A total of 171 patients were analyzed who had no loss of signal during IONM. It was observed that 94 of the patients (55%) had at least one previous surgery and 77 (45%) underwent their first operation. Ninetyone patients were monitored with continuous-IONM and 80 with intermittent-IONM. All patients’ preoperative and postoperative laryngeal examinations were identical and no postoperative vocal cord problems were observed.
Conclusion: The signal from the vagus nerve is sufficiently sensitive to show the postoperative vocal cord functions after resection in patients having no loss of signal during IONM. We support the idea that postoperative vocal cord examination may be neglected in these patients.

Objective: To evaluate the mechanisms of recurrent laryngeal nerve (RLN) injury during thyroidectomy and the impact of continuous intraoperative nerve monitoring (C-IONM) on surgical strategy.
Material and Methods: The data of 364 consecutive patients who underwent total or hemithyroidectomy between June 2014 and January 2016 were evaluated prospectively. All patients underwent thyroidectomy by using C-IONM. The mechanisms of RLN injury and the outcomes of the patients with combined events (CE) and loss of signal (LOS) were evaluated.
Results: Combined events (CE) occurred in 6 (1.6%) of these 364 patients. The reduced electromyographic (EMG) amplitude and prolonged latency recovered in all patients intraoperatively by the reversal of the medial traction maneuver. Loss of signal (LOS) occurred in 7(1.9%) patients. The mechanisms of LOS was ligation of the anterior branch of the nerve in 1 (14.3%) patient and traction in 4(57%) patients. The probable mechanism of LOS was traction or transection in 2 (28.6%) patients in whom LOS occurred during the dissection of the intrathoracic portion of large substernal goiter. Of these 7 patients, LOS recovered intraoperatively after 20 minutes of waiting in 1(14.3%) patient. In the remaining 6 (85.7%) patients, unilateral vocal cord paralysis (VCP) was verified on the postoperative laryngoscopic examination. The overall temporary and permanent unilateral VCP rates were 1.6% (n=6) and 0.8% (n=3), respectively in these 364 patients. No bilateral VCP was recorded. Continuous intraoperative nerve monitoring (C-IONM) prevented bilateral VCP in 1 (0.3%) patient.
Conclusion: The major advantage of C-IONM is to alert the surgeon for imminent RLN injury. Combined event (CE) is a pathognomonic sign of impending nerve injury that may progress to LOS. This situation enables the surgeon to adverse (reverse) the surgical maneuver before permanent damage to the nerve sets in. Continuous intraoperative nerve monitoring (C-IONM) can also immediately spot RLN injury during thyroidectomy. This property of C-IONM gives the surgeon the opportunity for an early corrective action to release the affected nerve promptly. In case of permanent LOS, staged thyroidectomy could be planned to prevent bilateral VCP.

Objective: The tethered cord syndrome (TCS) refers to lesions that can cause the conus medullaris to be low-lying or incapable of movement within the spinal canal. Tight conus medullaris is untethered by microneurosurgical operation. Patients may have additional persistent or transient neurological deficits in postoperative follows. The use of intraoperative neurophysiological monitoring (IONM) reduces risks of being neurological deficits. In our article, we aimed to show the importance of using intraoperative neurophysiological monitoring with results of cases operated in our department.
Material and Methods: The results of IONM findings, preoperative and postoperative neurological findings of 30 patients who were operated in our clinic between 2015-2016 were reported. Intraoperative neurophysiological monitoring (IONM) was used in all cases with tethered cord sydrome. Somatosensory evoked potential (SEP), motor evoked potential (MEP), free-run EMG responses, external sphincter muscle MEP and direct monopolar probe-evoked potentials were recorded.
Results: There were 20 male and 10 female patients with a mean age of 9.03 in our study. There was an increase in SEP values in only one of the cases. Additional neurological deficit arised in three cases; 1 transient (48 hours) and 2 persistent.
Conclusion: As our and other studies in literature has shown that using appropriate monitorization with experienced team decreases the risk of developing neurological injury; IONM should be used with its all modalities

Objective: To determine the knowledge and attitudes of healthcare professionals regarding vitamin D supplementations in pregnant and breastfeeding mothers.
Material and Method: Our study was conducted between April and May 2015 with the participation of 752 healthcare professionals (pediatrician, pediatric resident, specialist family physician, family physician resident, general family practitioner and nurse). The study questionnaire was created by researchers in accordance with experiences and literature information. Ethics committee approval was obtained. In questionnaire along with the demographic characteristics of the participants, the knowledge and practices on vitamin D supplementation for pregnant women and nursing mothers were asked. The data were analyzed by percentage and chi-square tests.
Results: A total of 574 physicians (76.4%) and 178 nurses (23.6%) participated in our study. Of these, 418 (55.6%) participiants suggested vitamin D supplementation to pregnants. The ratio of family physician specialists’ recommendations of vitamin D supplementation (66.7%) was higher than the other groups (p<0.001). The highest dose of vitamin D supplementation suggested to pregnants was 800-1000 IU/day with a rate of 23.4%. A total of 451 of participiants (60.0%) recommend vitamin D supplementation to breastfeeding mothers. Pediatric residents and specialists’ recommendations of vitamin D supplementation rate (70.0% and 63.6%, respectively) were higher than the other groups (p<0.001). Highest rate of vitamin D supplementation recommended to breastfeeding mothers was 800-1000 IU/day with a rate of 27.0%. The rate of recommendation according to the Ministry of Health’s recoomendations to pregnant women with 1200 IU/day of vitamin D was 6.0% and breastfeeding mothers with 1200 IU/day of vitamin D was 4.5%.
Conclusion: We found that the rate of recommendation and doses of vitamin D supplementation to breastfeeding mothers and infants by healthcare professionals were low in our study. It has been determined that training programs for healthcare professionals should be organized in order to prevent vitamin D deficiency.

Objective: Asthma is the most common chronic inflammatory disease of airways in children worldwide. It was speculated that in the presence of atopy, asthma severity and control show alteration. In this study we aim to investigate the association between atopy and asthma control
and asthma severity.
Material and Methods: Children between 6-17 years of age with diagnosis of persistent asthma, being followed in pediatric allergy and pulmonology clinics between November 2015 and January 2016 were involved. At enrollment, sociodemographic and asthmatic characteristics were investigated and asthma severity were determined and asthma control test (ACT) were administered.In order to determine the presence of atopy, the IgE levels, skin prick test and inhalant panel tests were obtained from the records. The IgE levels, skin prick tests, and inhalant panel tests were compared to asthma severity and asthma control.
Results: Out of 106 patients, 60 (56.6%) were male and 46 (43.0%) were female. The mean age was 11.2±2.7 years. There was no association between the presence of atopy and asthma control (p=0.764). The serum IgE levels, skin prick tests and serum specific inhalant allergens were significantly high in patients with severe persistant asthma (p=0.022).
Conclusion: There is an association between the presence of atopy and asthma severity but there is no association between the presence of atopy and asthma control.

Objective: Atherosclerosis is very common in patients with diabetes mellitus (DM). We aimed to investigate the relationship between asymmetric dimethylarginine (ADMA) which is known as ‘an endogenous inhibitor of nitric oxide synthase’ and atherosclerosis among patients with a diagnosis of type 2 DM.
Material and Methods: A total of 85 patients with a diagnosis of type 2 DM (48.2% [n: 41] male) with a mean age of 55.73±8.78 years were enrolled in this trial. Plasma levels of ADMA, and laboratory parameters such as lipid profile and HbA1c were evaluated. Carotid intima-media thickness (IMT), a marker of atherosclerosis was measured. The patients were classified into two groups as cases with
high and low ADMA levels.
Results: No statistically significant correlation was found between serum ADMA levels and total cholesterol (r=0.045; p=0.684), triglyceride (r=-0.067; p=0.544), LDL cholesterol (r=0.142; p=0.194) and HDL cholesterol (r=0.085; p=0.085). A statistically significant correlation was determined between serum ADMA level and HbA1c (r=0.376; p=0.001) and between serum ADMA level and carotid-intima media thickness (r=0.321; p=0.003).
Conclusions: Serum ADMA level is correlated with carotid IMT. Evaluation of ADMA levels in type 2 DM patients may be helpful in predicting atherosclerotic diseases such as coronary artery disease.

Objective: Spontaneous rectus sheath hematoma is a rare and often overlooked cause of acute abdominal pain. In this study, we aimed to present the results of patients with rectus sheath hematoma who received conservative treatment.
Materials and Methods: In this study, the demographic data, complaints, medical history, and data pertaining to the treatment provided to 9 patients were retrospectively retrieved from the computerized patient record system and imaging archives. The included patients presented with abdominal pain to our hospital’s emergency room between January 2010 and 2016, were diagnosed with spontaneous rectus hematoma, and received conservative treatment.
Results: The female/male ratio of the 9 patients who participated in this study was 1: 2, and the average age was 48.8 years. All the patients were admitted to the emergency department with abdominal pain. Three patients had a history of oral anticoagulant use, 3 patients had a history of hypertension, and 1 patient had a history of chronic obstructive pulmonary disorder. No predisposing factor was detected in the other 2 patients. There was a history of severe cough in 4 patients prior to their complaints; however, there was no history of coughing, trauma, or a surgery that would lead to this condition in the other patients. Five of the 9 patients received conservative treatment as inpatient treatment for rectus hematoma, while 4 patients received it as outpatient treatment. The average duration of hospital stay of the patients was 3 days. A cerebrovascular infarction that did not cause permanent damage developed in 1 patient 2 weeks after discharge. No additional morbidity or mortality was observed in any of the other patients.
Conclusion: Spontaneous rectus sheath hematoma should be considered in the differential diagnosis of abdominal pain that occurs after a persistent cough, particularly in patients receiving anticoagulant therapy. It is thought that the cases respond well to conservative treatment for etiology.

Objective: The umbilicus is a significant component of the abdomen. The size, position, depth, and shape of the umbilicus, as well as the location of the scar, are very important. While various techniques have been described in order to obtain an aesthetically appealing umbilicus, surgeons still frequently encounter complications such as visible scars and scar contractures. We present a technique that can
avoid these complications while also fulfilling the aesthetic umbilicus criteria.
Materials and Methods: Between 2011 and 2014, 18 female patients underwent both abdominoplasty and umbilicoplasty, which was performed using our technique. During abdominoplasty, the umbilicus was separated from the abdominal skin as a three-armed star and inserted in a Y-shaped incision. The patients were asked to evaluate and rate their new umbilici in terms of shape, depth, location, and
scaring.
Results: The mean follow up period was 20 months. No umbilical complications, such as hypertrophic scarring, were observed. In general, 80% of the patients gave the procedure an 8-point rating out of a possible high of 10-point rating, indicating their satisfaction with the results.
Conclusion: In this described technique, the umbilicus is small, shallow, and oval, and the scar is less visible. The incidence of the most frequent complications, such as scar contracture and umbilical stenosis, occurs less often in our safe and versatile technique.

Objective: Corticosteroid (CS) therapy is widely used as the standard treatment for acute exacerbations of multiple sclerosis (MS). Avascular necrosis (AVN) of the femoral head is one of the long–term complications related to CS therapy. Our study aims to investigate the association between annual and cumulative doses of CS treatment and radiographic assessment of AVN of the femoral head in MS.
Material and Methods: One patient group and two control groups were formed. The study group consisted 60 MS cases treated with intravenous methylprednisolone (IVMP) and the 2 control groups consisted 22 MS patients (Control I) without CS treatment and 25 healthy controls (Control II). Sixty patients who underwent CS treatment were divided into 3 subgroups of 20 cases each, treated with either IVMP only, IVMP and interferon, and IVMP and glatiramer acetate (GA). Neurological examinations and demographic data of all cases were recorded. The presence of AVN of femoral head in patient and control groups was evaluated using magnetic resonance imaging and Ficat staging system.
Results: Avascular necrosis (AVN) of femoral head was observed in 4 (6.7%) MS patients who were treated with CS. The mean annual CS dose was 8.07 g and mean cumulative dose was 31 gr. There was a significant but no statistical difference, in annual and cumulative IVMP doses between patients who have and don’t have AVN of femoral head (p=0.085 and p=0.246, respectively).
Conclusion: Our all data support the idea that annual dose of CS may increase AVN of femoral head development in MS patients. It is important to evaluate the CS-treated MS patients with MRI in this respect, due to the possible treatment of early-stage AVN of femoral head.

Objective: Symphysis pubis diastasis is an uncommon peripartum complication that might result in a serious distress to the patient. With pregnancy, the gap increases by at least 2 to 3 mm, which is thought to be caused by the slackness of ligaments supporting the joint. The diagnosis of diastasis is based on the persistence of symptoms and a symphysis pubis separation of more than 10 to 13 mm on imaging.
Case report: We report a 34-year-old multigravida woman with gestational diabetes at nearly 40 weeks of gestation and is presented with a spontaneous onset of pelvic pain, difficulty in walking after a shoulder distosi labor and diagnosed symphysis pubis diastasis.
Conclusion: After child birth if there is increasing pain with hip movement and pain causing prolonged immobilization, symphysis pubis diastase should be suspected and further investigation is recommended.