Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. MethodsWe did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. FindingsWe included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58•0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2•8 kg (2•3-3•3). Mortality among all patients was 37 (39•8%) of 93 in low-income countries, 583 (20•4%) of 2860 in middle-income countries, and 50 (5•6%) of 896 in high-income countries (p<0•0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90•0%] of ten in lowincome countries, 97 [31•9%] of 304 in middle-income countries, and two [1•4%] of 139 in high-income countries; p≤0•0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2•78 [95% CI 1•88-4•11], p<0•0001; middle-income vs high-income countries, 2•11 [1•59-2•79], p<0•0001), sepsis at presentation (1•20 [1•04-1•40], p=0•016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1•82 [1•40-2•35], p<0•0001; ASA 3 vs ASA 1-2, 1•58, [1•30-1•92], p<0•0001]), surgical safety checklist not used (1•39 [1•02-1•90], p=0•035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1•96, [1•4...

Hypopituitarism in adult life is commonly acquired and the main causes are known as pituitary tumors and/or their treatments. Since there are new insights into the etiology of hypopituitarism and presence of differences in various populations, more studies regarding causes of hypopituitarism are needed to be done in different ethnic groups with sufficient number of patients. Therefore, we performed a multi-center database study in Turkish population investigating the etiology of hypopituitarism in 773 patients in tertiary care institutions. The study was designed and coordinated by the Pituitary Study Group of SEMT (The Society of Endocrinology and Metabolism of Turkey). Nineteen tertiary reference centers (14 university hospitals and 5 training hospitals) from the different regions of Turkey participated in the study. It is a cross-sectional database study, and the data were recorded for 18 months. We mainly classified the causes of hypopituitarism as pituitary tumors (due to direct effects of the pituitary tumors and/or their treatments), extra-pituitary tumors and non-tumoral causes. Mean age of 773 patients (49.8 % male, 50.2 % female) was 43.9 ± 16.1 years (range 16-84 years). The most common etiology of pituitary dysfunction was due to non-tumoral causes (49.2 %) among all patients. However, when we analyze the causes according to gender, the most common etiology in males was pituitary tumors, but the most common etiology in females was non-tumoral causes. According to the subgroup analysis of the causes of hypopituitarism in all patients, the most common four causes of hypopituitarism which have frequencies over 10 % were as follows: non-secretory pituitary adenomas, Sheehan's syndrome, lactotroph adenomas and idiopathic. With regard to the type of hormonal deficiencies; FSH/LH deficiency was the most common hormonal deficit (84.9 % of the patients). In 33.8 % of the patients, 4 anterior pituitary hormone deficiencies (FSH/LH, ACTH, TSH, and GH) were present. Among all patients, the most frequent cause of hypopituitarism was non-secretory pituitary adenomas. However, in female patients, present study clearly demonstrates that Sheehan's syndrome is still one of the most important causes of hypopituitarism in Turkish population. Further, population-based prospective studies need to be done to understand the prevalence and incidence of the causes of hypopituitarism in different countries.

Background: To determine the level of knowledge on human papillomavirus (HPV) infection and vaccination, and the attitude towards HPV vaccination in pediatricians, obstetricians and gynecologists (OBG). Materials and Methods: Participants were administered a 40-question survey, investigating the demographic properties, the knowledge on the HPV infection-vaccination and attitudes towards vaccination. Results: The study enrolled a total of 228 participants (131 pediatricians and 97 OBGs). At a rate of 99.6%, the participants agreed with the fact that the HPV infection was the most common sexually transmitted disease and 33.8% of the participants had the opinion that the HPV vaccination should be administered only in women. The lowest level of HPV vaccine recommendation was among the pediatrics specialists (59.4%, p=0.012). When asked whether they would have their daughters receive HPV vaccination, 79.5% of the participants answered favorably; this rate was 36.7% for the sons. At a rate of 59.5% of the participants thought that the HPV vaccine needed to be included in the national vaccine schedule. Most of the participants (91.6%) had the idea that reduction of the vaccine costs would increase the vaccination frequency. Conclusions: We observed that the consideration of the costs and the prejudices relating to the inefficacy of vaccination as well as the inadequate level of knowledge were involved in the physicians' resistance to HPV vaccination. We believe that the healthcare professionals should be informed adequately to overcome false beliefs, thereby ensuring success of the HPV vaccine upon inclusion in the national vaccine schedule in the future.

ObjectiveTo investigate the early neonatal outcomes of very-low-birth-weight (VLBW) infants discharged home from neonatal intensive care units (NICUs) in Turkey.Material and methodsA prospective cohort study was performed between April 1, 2016 and April 30, 2017. The study included VLBW infants admitted to level III NICUs. Perinatal and neonatal data of all infants born with a birth weight of ≤1500 g were collected for infants who survived.ResultsData from 69 NICUs were obtained. The mean birth weight and gestational age were 1137±245 g and 29±2.4 weeks, respectively. During the study period, 78% of VLBW infants survived to discharge and 48% of survived infants had no major neonatal morbidity. VLBW infants who survived were evaluated in terms of major morbidities: bronchopulmonary dysplasia was detected in 23.7% of infants, necrotizing enterocolitis in 9.1%, blood culture proven late-onset sepsis (LOS) in 21.1%, blood culture negative LOS in 21.3%, severe intraventricular hemorrhage in 5.4% and severe retinopathy of prematurity in 11.1%. Hemodynamically significant patent ductus arteriosus was diagnosed in 24.8% of infants. Antenatal steroids were administered to 42.9% of mothers.ConclusionThe present investigation is the first multicenter study to include epidemiological information on VLBW infants in Turkey. Morbidity rate in VLBW infants is a serious concern and higher than those in developed countries. Implementation of oxygen therapy with appropriate monitoring, better antenatal and neonatal care and control of sepsis may reduce the prevalence of neonatal morbidities. Therefore, monitoring standards of neonatal care and implementing quality improvement projects across the country are essential for improving neonatal outcomes in Turkish NICUs.

This study compares NT proBNP and troponin T levels in umbilical cord arterial blood and postnatal echocardiographic findings for infants of gestational and pregestational diabetic mothers and macrosomic infants. Twenty-seven infants of pregestational diabetic mothers, 61 infants of gestational diabetic mothers and 37 macrosomic infants of nondiabetic mothers were prospectively enrolled in this study along with a control group of 58 healthy infants of mothers without any pregestational or gestational disorders as the control group. All enrollees were born after 34 weeks of gestation. For this study, umbilical cord blood was drawn during delivery to determine NT proBNP and troponin T levels. Echocardiography was performed 24-72 h after the delivery. Umbilical cord troponin T and NT proBNP levels were found to be higher in the diabetic and macrosomic groups than in the control group (all of them p < 0.001). NT proBNP levels were positively correlated with interventricular septum thickness in the pregestational and gestational infants of diabetic mothers groups (r = 0.564 and r = 0.560, respectively, p < 0.01). Both pregestational and gestational diabetic mothers were divided into two groups according to HbA1c levels in the third trimester as good (<6.1 %) and suboptimal (>6.1 %) metabolic control. In the good and suboptimal metabolic control diabetic groups, NT proBNP levels were also positively correlated with interventricular septum thickness (r = 0.536 and r = 0.576, respectively, p < 0.01). In the suboptimal metabolic control diabetic group, NT proBNP was only found to be positively correlated with the left ventricular mass index (r = 0.586, p < 0.01). While there was no correlation in the myocardial performance index between infants of diabetic mothers and the control group, the myocardial performance index of macrosomic infants was lower than that of the control group (p = 0.017). Cardiac biomarkers (NT proBNP and troponin T) were elevated in infants of diabetic mothers and macrosomic infants. While there was a positive correlation between NT proBNP levels and cardiac structure in infants of pregestational and gestational diabetic mothers, there was no relationship between NT proBNP levels and cardiac function.

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Amniotic band syndrome is a group of sporadic congenital anomalies that involve the limbs, craniofacial regions and trunk, ranging from simple digital band constriction to complex craniofacial and central nervous system abnormalities. Placento-cranial adhesions in amniotic band syndrome are extremely rare, and severe conditions are associated with high morbidity and mortality rates. In this study, we pooled placento-cranial adhesion case reports that were published in the medical literature and added an unpublished case from our institution. The purpose of this article was to review and discuss the clinical features and outcomes of placento-cranial adhesions in amniotic band syndrome.

Methodsby an interventional radiology expert. Subclavian vein was not preferred since it complicated the insertion of the catheter into the clavicle under ultrasound guidance. Adequate anesthesia was achieved prior to the procedure (1 μgr/kg fentanyl); sedation was ensured using midazolam (0,1 mg/kg) or ketamine (1-2 mg/kg). During the procedure, the patients were followed under continuous monitoring of the cardiac rate and rhythm, the respiratory rate and oxygen saturation. Except emergency situations, patients with pre-existing thrombocytopenia and abnormal coagulation test results were given supportive treatment and the catheter was inserted in these patients after the test results returned to normal. Central venous catheters were inserted by the pediatricians employed at the intensive care unit or interventional radiology expert at the pediatric intensive care unit. Double-lumen 4-Fr, triple-lumen 5-Fr, triple-lumen 7-Fr polyurethane transient catheters were used for patients with a body weight below 5 kg, between 5 and 20 kg and above 20 kg, respectively (Guangdong Baihe Medical Technology, China).For the purpose to recognize artery and vein; 1-the anatomic positions of internal jugular and femoral veins relative to arteries (internal jugular vein lies on the lateral side of the common carotid artery, femoral vein lies on the medial side of the femoral artery) (figure 1,2), 2-the compressibility of the internal jugular and femoral veins relative to arteries (figure 1,2), 3-in case of difficulty of discriminating the veins and arteries, the shape of the flow was investigated using Doppler mode of ultrasound (Figure 3). While transverse access was mostly used due to the size of the ultrasound probe, CVC was conducted using longitudinal access with real-time images in older patients (figure 4).Hand hygiene and aseptic conditions were ensured to manage infections. The site of administration was sterilized using 10% povidone iodine. A sterile ultrasound gel (Aquatouch Jelly, Turkey) and sterile transducer cover (Medbar Cardboard Camera Cover, Turkey) was used. While inserting the catheter, a "laptop style" ultrasound device and a straight linear probe (7.5 MHz) was used (Mindray-M5 Ultrasound System, China). The catheters were inserted using the Seldinger technique. The location of the catheter was assessed by posterior-anterior chest radiograph for the internal jugular catheters and the localization was deemed appropriate if the tip of the catheter was in the space between the distal part of vena cava superior and the entrance of the right atrium. Dressings were applied once every two days. Patients exhibiting the same microorganism growth in the catheter culture and the peripheral blood culture with accompanying the sepsis clinical findings and signs were diagnosed as central line-associated bloodstream infection while those with erythema, indurations and tenderness within 2 cm distance around the catheter exit were diagnosed with catheter exit-site infection 9 .