Peripheral lymphadenopathy in childhood

Lenfadenopatilerin tanımlanması ve lenfadenopatiye yaklaşım pediatri pratiğinde sık tartışılan konulardan birisidir. Hasta veya sağlıklı çocuklarda lenf bezlerinin değerlendirilmesi, genel fizik incelemenin önemli bir parçasıdır. Lenfadenopati, lenf bezlerinin boyut, sayı veya kıvam özelliklerinde anormallik göstermesidir ve diğer bulgu ve semptomların bir parçası olabileceği gibi, tek bulgu veya ana yakınma olabilir. Ayırıcı tanıda birçok hastalık yer alır ve doğru yaklaşımda zorluk çekilebilir. Genellikle kendini sınırlayıcı, beniyn bir durum olabilmesine karşın altta yatan ciddi sistemik bir hastalığın veyamaliynitenin ipucu olabilir. Bumakalenin amacı lenfadenopati tanımı, bölgesel ve yaygın lenfadenopatinin ayırıcı tanısı, lenfadenopatili hastanın değerlendirilmesinde sistematik yaklaşım, acil biyopsi yapılması gereken durumlar gibi önemli noktaların gözden geçirilmesidir.The assessment of lymphadenopathy in children is a common diagnostic problemin pediatrics. Examining the lymph nodes is an important aspect of the general physical examination of both well and ill children and adolescents. The term “lymphadenopathy” refers to lymph nodes that are abnormal in size, number, or consistency. The majority of children with lymphadenopathy will have a benign, self-limited process. Conversely, the presence of lymphadenopathy can be a clue to a serious underlying systemic disease or malignancy, and the differential diagnosis of lymphadenopathy can be broad. The aim of this article is define lymphadenopathy, discuss the differential diagnosis of localized and generalized lymphadenopathy develop a systematic approach to the evaluation and management of lymphadenopathy, recognize worrisome features of lymphadenopathythat shouldprompt a referral fora biopsy

Numerical analysis of umbrella-arch method performed in metro tunnels

Tünel tasarımcıları, zayıf zeminlerde projelenen tüneller için inşa sırasında işçi ve yapım güvenliği ve özellikle şehir içinde daha da önem taşıyan yüzey oturmaları gibi kritik konuları denetim altına almak durumundadır. Bu çalışmada, zayıf zeminlerdeki tünel inşaatlarında tünelin göçmeden açılabilmesi ve tünel içi (konverjans) ve yüzey deformasyonlarını denetim altına almak için uygulanan şemsiye-kemer (umbrella-arch) yönteminin, tünel içi ve arazide oluşturduğu iyileşmelerin etkileri parametrik olarak incelenmiştir. Sayısal hesaplamalarda sonlu elemanlar yöntemi ile çalışan Plaxis yazılımı kullanılmıştır. Sayısal analizlerde, zemin davranışını temsil etmek amacıyla elastoplastik Mohr-Coulomb zemin modeli kullanılmıştır. Hesaplamalar, 2 boyutlu düzlem-gerilme ortamında elastik mesnetlere oturan kiriş kabulleriyle yapılmıştır. Yapılan sayısal modellemeler sonucunda şemsiye borularının uzunluklarının (Lp) en büyük yüzey oturmalarına (smaks) etkisi için farklı her tünel derinliğinde (Z) geçerli olabilecek bir bağıntıdan söz etmek mümkün görülmemektedir. Ancak, şemsiye borularının boylarının (Lp) artırılmasının oturmaların yüzey dağılımı üzerinde olumlu bir etki yaparak yüzey oturma bölgesini daralttığı anlaşılmıştır. Şemsiye-kemer borularının uygulama açısının yataydan uzaklaşması (b≠0o) yüzey oturma dağılımına ve aynada oluşan eksenel deformasyonlara (dx) olumsuz etki yaptığı, uygulama açısını artırmanın daha yüksek eksenel deformasyonlar verdiği görülmektedir. Şemsiye borularına verilecek en elverişli açının tünel eksenine paralel olduğu (b=0o) ve uygulamada boruların mümkün olan en küçük açı ile imal edilmesinin uygun olacağı sonucuna ulaşılmıştır. Şemsiye-kemer boru boylarının (Lp) tünel tavanı düşey deformasyonlarını her kazı kademesi için azalttığı görülmüştür. Şemsiye-kemer borularının boylarının (Lp) ayna yatay deformasyonlarını olumlu yönde etkilediği ve daha uzun boru boyu kullanmanın ayna yatay deformasyonlarını azalttığı görülmüştür. Anahtar Kelimeler: Mohr-Coulomb, zemin modeli, şemsiye-kiriş, elastik-kiriş, sonlu elemanlar.As a result of rapid urbanization, complex transportation networks have been built to overcome the demand for public transport. In urban areas the surface settlements (which take place during tunnel construction and service life) should be within the tolerance limits and should not effect nearby the superstructures. The tunnel excavation and support system should provide an adequate tunnel wall and face stability for worker and equipment safety and should prevent a possible collapse. The umbrella-arch method can be defined as a reinforcement technique which involves installing pipes ahead of the tunnel face prior to the excavation in order to limit the deformations that occur in the crown, face and surface settlements, in order to provide a longer stand-up time and to excavate the tunnel in safety. Quantifying the level of improvement provided by the reinforcements would enhance the design stage. The media in which a tunnel is going to be excavated would usually expose heterogenous and unisotropic properties and the tunnel route possesses varying cross-sections such as stations, rail switches, service depots etc. Therefore, there is a need to use simple and flexible methods that are applicable to different underground conditions. In this study, the effects of umbrella arch pipe roofing method on limiting the aforementioned deformations are investigated by numerical methods. Modelling each umbrella pipe individually by using 3D methods is not very efficient in application projects for the reasons summarized below; There are too many parameters affecting the reinforcement behaviour in tunnel excavation. Software chosen should be capable of reflecting the real in situ behavior of the material (stress-strain, long/short term behavior, pore-water pressures and movements, interaction between the support material etc.) in a convenient manner. Commercial software avaliable on the market are usually not user-friendly and requires extensive training. These 3D analyses require special and expensive hardware setups. Solution times are unacceptably long for the conditions where a quick respond is needed. These points urge the engineer to use more practical 2D software applications capable of reflecting the real in situ behaviour within a reasonable accuracy. This study presents the results of over 100 parametric Finite Element analyses of umbrella arch tunnel roof reinforcing based on two dimensional plane strain conditions with the assumption of beam on elastic multi-supports inserted in elastoplastic medium. Therefore, the analyses performed are on the longitudinal profile. In the constitutive model, the soil is discretized as 15 noded triangular elements; the umbrella pipes are modelled as beam elements of 5 nodes each of which has three degrees of freedom; the steel sets are modelled as strut elements which are one node spring elements of constant spring stiffness (normal stiffness) which are fixed at one end at a predefined length. The lateral far boundaries are taken at least eight times the diameter of the tunnel in order to obtain more accurate Finite Element Method (FEM) results. The vertical boundary of the model changes by the depth of tunnel. The out-of-plane dimension is taken as unit width (1m), therefore, some modifications are applied on the stiffness properties of beams. The tunnel is assumed to be excavated in a cohesive medium. For practical reasons it is assumed that no ground water exists. Total excavation length is 10m which is achieved by ten steps of 1m long advances. The cover depth (C), the length of umbrella pipes (Lp), the length of overlapping of pipes (Lo) and the application angle of pipes are the main constituents of parametric study. The results of parametric study show that it is not possible to deduce a general expression which is valid for all tunnel depths that the length of pipes (Lp), have a positive effect on decreasing maximum surface settlements (smax). However, the length of pipes has a possitive effect on narrowing the settlement trough, and decreasing the crown settlements and lateral face deformations (dx). The increase in the thickness of pipe reinforcing provides lining stability and limits the tunnel and surface deformations. Deviation of the application angle of pipes from horizontal plane, negatively affects the settlement trough, and lateral face. However, because it is not possible to place the pipes laterally due to the space that is occupied by the overlap, smallest minimum angle should be applied in order to achieve the best benefit from the method. Keywords: Mohr-Coulomb, soil model, FEM, forepole umbrella, elastic support.

Type B Lactic Acidosis in A Child with Relapsed non-Hodgkin Lymphoma

Lactic acidosis is a major cause of metabolic acidosis in critically ill patients. Herein we report a child with relapsed non-Hodgkin’s lymphoma admitted to the pediatric intensive care unit (PICU) with profound lactic acidosis. On admission, he was treated with fluid replacement and a vasopressor, followed by continuous veno-venous hemodiafiltration to correct acidosis. As lactic acid levels remained high despite all treatments, thiamine was added to the therapy, which did not influence metabolic status either. Lactic acidosis could only be corrected by aggressive chemotherapy during his stay in the PICU. The patient died on the 68th day of PICU admission due to underlying progressive disease. Clinicians should start aggressive chemotherapy as soon as possible in patients with a recurrence or advanced cancer who have type-B lactic acidosis

Characteristic Features of Children with Neurofibromatosis Type 1

Neurofibromatosis Type 1 (NF-1) is the most common, progressive, multisystemic, autosomal dominant neurocutaneous syndrome. Its clinical features begin to present during childhood. Early diagnosis and follow-up of children with NF-1 is necessary due to predisposition to tumors and complications. Herein we aimed to evaluate patient characteristics', neuroradiologic findings and frequency of tumors in children with NF-1 who have been followed up at our center from January 1989 to June 2008. Medical records of 64 children with NF-1 were analized retrospectively for age, gender, diagnostic criteria for NF-1, unidentified bright objects (UBOs) on magnetic resonance imaging (MRI), complications related to NF-1, and tumors. The median age of patients was 9.5 years (0.5 18), M:F ratio was 1.2. The incidence of the diagnostic criteria were as following, café au lait spots: 100%, freckling: 62.5%,neurofibromas ± plexiform neurofibromas: 47%, Lisch nodules: 38%, optic gliomas: 11%,distinctive osseous lesions: 11%, and first degree relative with NF- 1: 30%. Cranial MRI had been performed in 38 patients, and 58% of them revealed UBOs. The most common complications were kyphoscoliosis (19%), convulsion (11%). Benign tumors and malignant ± benign tumors developed in52%and19%of patients, respectively. The importance of careful physical examination was showed by the high frequency of positive clinical diagnostic criteria of NF-1. The frequency of UBOs on MRI was high in children with NF-1. This was suggested that neuroradiologic findings may be proposed as an additional diagnostic criterion for NF-1, particularly for young children who didn't meet the diagnostic criteria. Management and follow up of complications related to NF-1, and offering genetic counseling to parents could be making by early diagnosis of NF-1 in childhood. The predisposition to tumors and the high frequencies of complications related to NF-1 were showed that the importance of multidisciplinary follow up of children with NF-1.Nörofibromatozis Tip1 (NF1) toplumda en sık karsılasılan, klinik bulguları çocukluk çagında ortaya çıkmaya baslayan, zamanla ilerleyici seyir göstererek pek çok sistemi etkileyebilen otozomal dominant geçisli bir nörokutan sendromdur. Beniyn ve maliyn tümör gelismesine yatkınlık yaratması ve NF1 iliskili komplikasyonlar nedeniyle, NF1' in çocukluk çagında erken tanısı ve klinik izlemi önemlidir. Bu çalısmada merkezimizde Ocak 1989-Haziran 2008 tarihleri arasında, NF1 tanısıyla izlenen çocuk hastaların karakteristik özellikleri, nöroradyolojik bulguları ve tümör sıklıgınındegerlendirilmesi amaçlanmıstır. Nörofibromatozis Tip1 tanı kriterlerini karsılayan 64 hastanın dosyaları retrospektif olarak incelendi. Hastaların yas, cinsiyet, NF1 tanı kriterleri, manyetik rezonans görüntülemede (MRG) tanımlanmamıs parlak objelerin (UBO: unidentified bright objects) görülme sıklıgı, NF1 iliskili komplikasyonlar, gelisen tümörler degerlendirildi. Hastaların ortanca tanı yası 9.5 yas (0.5 18), E:K oranı 1.2 bulundu. Tanı kriterlerinin sıklıgı: sütlü kahve lekeleri %100, çillenme %62.5, nörofibrom veya pleksiform nörofibrom %47, Lisch nodülü %38, optik gliom %11, kemik lezyonu %11, birinci derece akrabalarda NF1 tanısı %30 bulundu. Kraniyal MRG yapılan 38 hastadan 58%'inde UBO mevcuttu. En sık gelisen komplikasyonlar; kifoskolyoz (%19) ve konvülzyondu (%11). Hastaların %52'inde beniyn, %19'inde maliyn±beniyn tümörler gelismisti. Nörofibromatozis Tip1'in fizik inceleme ile saptanabilen klinik tanısal kriterlerinin sıklıgı, iyi bir fizik incelemenin önemini göstermektedir. Kraniyal MRG ile NF1 tanılı çocuk hastalarda yüksek oranda UBO pozitifligi izlendigi görülmüstür. Bu bulgu, özellikle henüz klinik bulguları NF1 kriterlerini karsılamayan küçük yas grubunda nöroradyolojik bulguların ek bir kriter olarak arastırılmasının hastaların erken tanısını saglayabilecegini düsündürmektedir. Erken tanı ile hem çocukta gelisebilecek problemlerin izlemi ve tedavisi, hem de ailelere genetik danısma verilmesi saglanabilecektir. Beniyn ve maliyn tümörlere yatkınlık ve diger NF1 iliskili komplikasyonların sıklıgının yüksek olması, NF1 tanılı çocukların multidisipliner izleminin önemini göstermistir

The time to diagnosis in childhood lymphomas and malignant solid tumors

AMAÇ: Çocukluk çağı kanserlerinde tanı süresi ve bunu etkileyen faktörler hakkında gelişmekte olan ülkelerde az sayıda çalışma vardır. Çalışmanın amacı ülkemizde çocukluk çağı kanserlerinde tanı süresini ve bunu etkileyen faktörleri belirlemektir. YÖNTEM: Lösemi dışında kanser tanısı almış 329 hasta retrospektif olarak değerlendirildi. Aile/hasta gecikmesi ve doktor gecikmesinin toplamından oluşan toplam tanı süresi, semptomların başlangıcından kesin tanı konuncaya kadar geçen zaman olarak tanımlandı. SONUÇLAR: Aile/hasta gecikmesi, doktor gecikmesi ve toplam tanı süresi ortanca süreleri sırası ile, 3, 28 ve 53 gün olarak saptandı. Doktor gecikmesi ve toplam tanı süresi 1-9 yaş grubunda, infant ve 10 yaşından büyüklere göre anlamlı olarak daha kısa bulundu. En uzun tanı süresi germ hücreli tümörlerda ve retinoblastomda, en kısa ise böbrek tümörlerindeydi. İlk başvurulan hekim pediatrist ise, özel hastane, özel ofis, eğitim hastanesi veya üniversite hastanesi ise tanı süresi kısa bulundu. İlk olarak pediatri uzmanı dışında başka branş uzmanlarına başvuran hastalarda en uzun tanı süresi saptandı. Aile/hasta gecikmesi, doktor gecikmesi ve toplam tanı süresi üzerine en belirleyici faktörler sırası ile, tanı anında metastatik hastalık, ilk başvurulan merkez ve ilk başvurulan hekim olarak belirlendi. YORUM: Lenfoma ve diğer solid tümörlerde tanı süresi hasta yaşı, tümör tipi ve yerleşimi, metastaz varlığı, ilk başvurulan hekim ve merkeze bağlı olarak değişmektedir. Özellikle pediatrist dışındaki branş uzmanları olamak üzere, çocuk yaş grubu hasta gören tüm hekimlerin çocukluk çağı kanserlerinin semptom ve bulguları hakkında daha hassas olmaları gerekmektedir. PURPOSE: There are few reports from developing countries on the factors that influence the time to diagnosis (TD) in childhood cancer. The purpose of this study was to investigate the determinants of the TD in our country cancer patients. METHOD: A retrospective analysis was performed on 329 children diagnosed with cancer, excluding leukemia. The TD, including parent/patient time and physician time, was defined as the interval between the onset of symptoms and the final diagnosis. RESULTS: The median times for parent/patient, physician, and TD were 3, 28, and 53 days, respectively. For patient in the 1-9 years age group, physician time and TD were significantly shorter than in infants and those over 10 years. The longest median TD was recorded for children with germ cell tumors and retinoblastoma; the shortest was in children with renal tumors. When the first point of contact was a pediatrician, a private hospital or physician's office, a governmental educational hospital or a university hospital physician time was short. The longest TD was noted in patients who first contacted a non-pediatric specialist. The most significant predictors of parent/patient, physician time, and TD were metastases at diagnosis, first medical center, and first health professional contacted, respectively. CONCLUSION: The TD for childhood lymphomas and solid tumors was related to patient age, tumor type and location, the presence of distance metastases, first health professional, and center contacted. All physicians, especially other specialists seeing pediatric patients, need to be further sensitized to the signs and symptoms of childhood cancer

EVALUATION OF RECENT EARTHQUAKES IN ALBANIA

Earthquakes are natural phenomena that impact the life of inhabitants who live in zones prone to them. It is of great importance to understand the mechanism in order to undertake adequate precautions and design improvements to have a more resistant urban infrastructure. This article takes into consideration the issues related to structural problems caused by the two earthquakes that shook Albania (September 21 and November 26) in 2019.A considerable number of structures suffered a lot of damages and a substantial amount was destroyed. The team of structural engineers did inspection and post assessment immediately after these incidents. This paper shares some of the findings achieved during these inspections. We find it necessary to summarize in a structural engineering point of view the main causes that the buildings suffered through these earthquakes. Moreover, we added some recommendations in order not to repeat the errors of for the future. This study also includes comparisons between Albanian seismic codes of construction and their equivalent Eurocodes and evaluates the adoption of them to nationwide

SEISMIC STUDY OF HISTORICAL CASTLES AND THE EFFECT OF SOIL STRUCTURE INTERACTION : CASE STUDY OF THE CASTLE OF BASHTOV

Historical buildings and monuments of built heritage in Albania suffered great damages during the earthquake of 26 November 2019. Most of them have a structural system of traditional load bearing stone masonry. Field observations and the overview of past interventions of several objects, suggested that the reported damages might have underlying causes, which triggered the main damages during the earthquake. This article focused on the study of damages of stiff masonry walls in castles and their relationship with the earthquake. We took as a case study the Castle of Bashtova, which is one of the few Albanian Castles located in flat terrain and on poor soil conditions. The purpose of this paper is the study of the link between the recorded damages through the history of the structure, the reported damages and the numerical analysis performed for the purpose of structural consolidation interventions. The analysis performed was the linear dynamic analysis with the response spectrum procedure for the calculation of stresses, displacements and their distributions, along with checks of the overall stability of the most critical sections with the Virtual Work Principle. The physical and mechanical properties of the materials were determined in laboratory and in-situ. The study showed that most of the damages reported after the earthquake were due to local effects of soil deposits or soil-structure interaction, local degradation of masonry and not sufficiently connected walls of different phases of construction