Abdullah Durmaz

Gulhane Military Medical Academy, Engüri, Ankara, Turkey

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Publications (43)27.22 Total impact

  • A Durmaz · A Kilic · R Gumral · U Yildizoglu · B Polat
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    ABSTRACT: Objective: To investigate the effects of different suture materials in the nasal cavity on encrustation and micro-organism colonisation. Methods: Four different suture materials were used to suture the nasal septum. The effects of suture materials on intranasal encrustation were evaluated with anterior rhinoscopy. The sutures were removed and evaluated in terms of micro-organism colonisation on the 7th and 21st post-operative days. Results: Monofilament sutures were found to cause less encrustation and micro-organism colonisation. There was increased late-stage encrustation if an absorbable monofilament suture remained in place for a long time. The removal of a non-absorbable monofilament suture in the early or late post-operative period made no difference in terms of micro-organism growth on the suture. Conclusion: The material and physical characteristics of sutures placed inside the nose may indirectly affect the healing process. It may be more appropriate to use different materials depending on the length of time the suture is to remain in place.
    No preview · Article · Feb 2016 · The Journal of Laryngology & Otology
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    Mehmet Burak Asik · Bahtiyar Polat · Abdullah Durmaz · Yusuf Uysal
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    ABSTRACT: Fibrous dysplasia of the paranasal sinuses is mostly asymptomatic, but sometimes may cause signs and symptoms depending on its location. We report two cases of maxillary fibrous dysplasia obstructing the lacrimal drainage system as a reason of chronic dacryocystitis, and reviewed the related literature. The first case underwent an endonasal endoscopic approach combined with external dacryocystorhinostomy. He had a patent lacrimal system at one-year follow-up. The lesion was completely removed via an endonasal endoscopic approach in the second case, wherein the patient was asymptomatic of the six-month follow-up period.
    Full-text · Article · Sep 2015
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    Bahtiyar Polat · Mehmet Burak Asik · Abdullah Durmaz · Yusuf Uysal
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    ABSTRACT: Fibrous dysplasia of the paranasal sinuses is mostly asymptomatic, but sometimes may cause signs and symptoms de-pending on its location. We report two cases of maxillary fibrous dysplasia obstructing the lacrimal drainage system as a reason of chronic dacryocystitis, and reviewed the related literature. The first case underwent an endonasal endoscopic approach combined with external dacryocystorhinostomy. He had a patent lacrimal system at one-year follow-up. The le-sion was completely removed via an endonasal endoscopic approach in the second case, wherein the patient was asymp-tomatic of the six-month follow-up period.
    Full-text · Article · Aug 2015
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    ABSTRACT: Dermoid cysts are rare, benign, congenital ectodermal inclusion cysts in the skull base, comprising skin supplements surrounded by squamous epithelium. In the period of embryological development, the cysts originate from ectodermal cells left behind in the cranial region by the closure of the neural tube and are primarily located at the midline, especially in the subarachnoid spaces. These lesions are usually asymptomatic and diagnosed incidentally. When the cysts reach large sizes, they can be symptomatic due to infection, rupture, or mass effect around neurovascular tissue. The cysts typically demonstrate accurate radiological diagnostic features. In this case report, we present a rare dermoid cyst in the middle cranial fossa, treated by an endonasal endoscopic approach. The endonasal endoscopic management of appropriate middle cranial fossa is discussed as a recent advance in the extended applications of endoscopic sinus surgery.
    No preview · Article · Jun 2015 · The Journal of craniofacial surgery
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    ABSTRACT: Objective In this study, we aimed to investigate the presence and copy number of six different viruses in tonsillar tissue samples removed surgically because of chronic recurrent tonsillitis or chronic obstructive tonsillar hypertrophy. Methods In total, 56 tissue samples (tonsillar core) collected from 44 children and 12 adults were included in this study. The presence of viruses was investigated using a new TaqMan-based quantitative real-time PCR assay. Results Of the 56 tissue samples, 67.9% (38/56) were positive for at least one of the six viruses. Epstein-Barr virus was the most frequently detected virus, being found in 53.6% (30/56), followed by human parvovirus B19 21.4% (12/56), human adenovirus 12.5% (7/56), human cytomegalovirus 5.4% (3/56), BK polyomavirus 1.8% (1/56), and herpes simplex virus 1.8% (1/56). Precancerous or cancerous changes were not detected in the tonsillar tissue samples by pathologic examination, whereas lymphoid hyperplasia was observed in 24 patients. In contrast to other viruses, B19 virus was present in high copy number in tonsillar tissues. The rates of EBV and B19 virus with high copy number (> 500.000 copies/ml) were higher in children than in adults, and a positive relationship was also found between the presence of EBV and the presence of B19 virus with high copy number (P = 0.037). Conclusions It is previously reported that some viral agents are associated with different chronic tonsillar pathologies. In the present study, the presence of B19 virus in tonsillar core samples was investigated quantitatively for the first time, and our data suggests that EBV infections could be associated with B19 virus infections or could facilitate B19 virus replication. However, further detailed studies are needed to clarify this observation.
    Full-text · Article · Aug 2014 · International Journal of Pediatric Otorhinolaryngology
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    ABSTRACT: Objectives: There are some subjective symptoms involving the nasal cavity such as nasal congestion during a migraine attack. In this study, we aimed to evaluate the possible changes occurring in the nasal cavity during headache in patients with migraine. Materials and methods: Patients with migraine were studied. The control group consisted of patients with tension-type headache. The severity of the headache and accompanying complaints were assessed using visual analog scale, and the nasal mucosa was assessed through anterior rhinoscopy and endoscopy. Resistance of the nasal cavity was evaluated through anterior rhinomanometry. Data obtained during the attack periods and attack-free periods were compared. Results: Twenty-five patients with migraine and 15 patients with tension-type headache were enrolled. It was found that 19 patients (76%) of the group with migraine and 5 patients of the group with tension-type headache were experiencing nasal congestion during the attack and that the differences between the groups were statistically significant (P < 0.05). The average of total nasal resistance in the patients with migraine was 0.57 ± 0.60 kPa/L/sn during migraine attacks and 0.28 ± 0.14 kPa/L/sn during attack-free periods. The average of total nasal resistance in the patients with tension-type headache was 0.32 ± 0.14 kPa/L/sn during attack periods and 0.31 ± 0.20 kPa/L/sn during attack-free periods. In the group with migraine, the change of nasal resistance between during the attack and attack-free periods was found statistically significant, whereas there was no statistically significant difference in the group with tension-type headache. Conclusions: According to the results of this study, complaints regarding nasal obstruction and nasal airway resistance increase during migraine attacks. Cause-and-effect relationship between nasal obstruction and pain is not clear, and clinical trials are needed to determine the effect of nasal obstruction treatment (mucosal decongestion, etc) on the complaint of pain.
    No preview · Article · Jul 2014 · Journal of Craniofacial Surgery
  • Fuat Tosun · Uzeyir Yildizoğlu · Bahtiyar Polat · Abdullah Durmaz
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    ABSTRACT: The aim of this study was to define the types of endoscopic endonasal resection for sinonasal malignancies according to their origin and extension. Patients who underwent endoscopic endonasal surgery for the removal of malignant tumors of the nasal passages, paranasal sinuses, and the anterior cranial base between 2003 and 2010 were included in the study. Patients' data were collected retrospectively. Patients were grouped according to types of endoscopic tumor resection as follows: type I: en bloc resection, type II: resection of intranasal free part piecemeal and origin of tumor en bloc, type III: resection of intranasal free part and origin of tumor piecemeal with curative intent, and type IV: resection of intranasal free part and origin of tumor piecemeal with palliative intent or removal of tumor with positive margin. The follow-up period varied from 2 to 7 years (mean, 4.35 years). Twenty patients were included in the study. Five patients underwent type I, 6 patients type II, 4 patients type III, and 5 patients underwent type IV resection. No local tumor recurrence was seen after types I, II, and III resections, whereas 2 patients (10%) with the type IV resection had a local recurrence. Distant metastasis was observed in 4 patients (20%) postoperatively (1 patient in type I, 1 patient in type III, and 2 patients in type IV resection). Disease-specific death was 15% (1 case in type I and 2 cases in type IV). Classification of endoscopic tumor resection used in the present study may help preoperative planning.
    No preview · Article · Jan 2014 · The Journal of craniofacial surgery
  • Umit Aydın · Altay Tolga Sentürk · Abdullah Durmaz · Fuat Tosun
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    ABSTRACT: This study aims to evaluate postoperative histopathological changes in ethmoid sinus mucosa in patients undergoing limited or extensive endoscopic sinus surgery (ESS) due to chronic rhinosinusitis. A total of 120 patients (74 males, 46 females; mean age 33 years; range 18 to 56 years) with chronic rhinosinusitis who underwent limited ESS (n=40), extensive ESS (n=40) and septoplasty or septorhinoplasty (n=40) in our clinic between May 2009 and October 2010 were enrolled. The control group consisted of patients who underwent septoplasty and septorhinoplasty alone. We took samples from the anterior ethmoid sinus mucosa at postoperative sixth months for the patients who underwent ESS and intraoperatively for the control patients. Tissue slices of mucosa samples were investigated under light microscope in terms of epithelial erosion, squamous metaplasia, submucosal fibrosis, basal membrane thickening, submucosal edema and submucosal inflammation. Histopathological findings of limited and extensive ESS groups were compared to each other and the control group. The incidence of squamous metaplasia and submucosal fibrosis was significantly higher in extensive ESS group, compared to limited ESS group (p=0.003 and p<0.001, respectively). Both of ESS groups had significantly higher incidences of epithelial erosion, submucosal fibrosis, basal membrane thickening, submucosal edema, submucosal inflammation, compared to the control group (p<0.001). Our study results show that ethmoid sinus mucosa may be still abnormal at the postoperative sixth month following ESS, regardless of the extension of ethmoidectomy. These patients should be followed closely, as they may have recurrent rhinosinusitis in the postoperative period due to impaired mucociliary activity.
    No preview · Article · Nov 2013 · Kulak burun bogaz ihtisas dergisi: KBB = Journal of ear, nose, and throat
  • Uzeyir Yildizoglu · Turker Turker · Abdullah Durmaz · Mustafa Cakar

    No preview · Article · Oct 2013 · Acta Radiologica
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    Yusuf Hidir · Hakan Genc · Abdullah Durmaz · Bulent Satar · Mustafa Gerek
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    ABSTRACT: Objective: The aim of the study was to determine effectiveness of intratympanic methyl prednisolone injection as a salvage therapy for sudden sensorineural hearing loss in patients who did not have complete recovery with systemic treatment. Material and Methods: Sixteen patients with sudden hearing loss who did not have complete recovery or had a partial recovery with systemic treatment enrolled in this prospective study. After the topical anesthesia, 0.4-0.5 mL of methyl prednisolone (40 mg/mL) was administered into the middle ear from the postero-inferior quadrant of the tympanic membrane. Pure tone audiometry test was performed before each injection and after the final injection. A change more than 10 dB in the pure tone average was considered as an alteration in hearing (improvement or worsening). Complete recovery was accepted when the pure tone average was 20 dB or lower. Results: The mean onset of intratympanic methyl prednisolone treatment after the hearing loss was 16 +/- 6.6 days (range: 7-30 days). The average number of injections was 3.8 +/- 1.3 (range: 2-6). The improvement in pure tone average was statistically significant [initial median of pure tone average was 85 dB (minimum 28 dB, maximum 107 dB), final median of pure tone averages was 42.5 dB (minimum 12 dB, maximum 107dB), p=0.007]. Eleven (68.75%) patients improved, but no change was observed in 5 (31.25%) patients. Two (12.5%) patients attained complete recovery. Four (25%) patients improved to 30 dB or less in pure tone average. Statistically significant improvement was also obtained at 250, 500, 1,000, 2,000, 4,000 and 6,000 Hz frequencies. Conclusion: These results suggested that intratympanic methyl prednisolone treatment for sudden hearing loss in patients who did not respond to systemic therapy appears to be a good alternative for better hearing results.
    Preview · Article · Dec 2012 · Turkiye Klinikleri Journal of Medical Sciences
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    ABSTRACT: Surgical approaches to the anterior cranial base have changed considerably with the introduction of endonasal endoscopic surgery. This study aims to define the factors which help in selecting the optimal surgical approach for the treatment of anterior cranial base encephaloceles. Patients who received treatment for anterior cranial base encephaloceles at our department between 1996 and 2011 were included in the study. Patients' charts were reviewed retrospectively to collect the necessary data. Treatment periods were classified as before 2000, between 2000 and 2005, and after 2005. The relationship between the treatment period, localization of encephalocele, symptoms related with the lesion, size of skull base defect, and selected treatment modality were investigated. Twenty-five patients, aged between 1 and 61 years with anterior encephaloceles were included in the study. Patients with small asymptomatic frontonasal and trans-ethmoidal encephaloceles (n = 5) were followed without surgery. An external approach with or without subfrontal craniotomy was mainly preferred for resection of sincipital encephaloceles (n = 10), especially with facial deformity. A subfrontal craniotomy approach was used for resection of basal encephaloceles in two cases before 2000. Two cases with sincipital encephaloceles and six cases with basal encephaloceles underwent pure endonasal endoscopic surgery after 2000. Cranial base defects of every size could be repaired using the endoscopic approach. Hydrocephalus and meningitis were the two complications seen after craniotomy in a follow-up period of 13-26 (mean 14.5) months. An external approach with or without craniotomy is needed for encephaloceles with external mass and facial deformity. Otherwise, sincipital and basal encephaloceles can be repaired successfully using the endonasal endoscopic approach.
    No preview · Article · Sep 2012 · Archives of Oto-Rhino-Laryngology
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    ABSTRACT: Pollybeak deformity due to abundant fibrosis formation in the supratip region after rhinoplasty is still a common problem. The aim of this study was to investigate the effects of a modified subcutaneous approximation suture on pollybeak deformity of soft tissue origin. Three groups, each consisting of eight rabbits, were included in the study. Nasal skin was elevated with an open rhinoplasty approach in all groups. During closure of the skin, to minimize supratip dead space, a horizontal subcutaneous approximation suture was used in group I, external tape fixation was used in group II, and no further action was taken for supratip skin approximation in the control group. Full-thickness supratip skin biopsy specimens reaching down to the underlying cartilage tissue were taken from each subject on the 60th day after the operation. Thicknesses of subcutaneous scar tissues were measured histologically in all groups and compared. The mean thickness of the subcutaneous scar tissues was significantly lower (0.98 ± 0.32 mm) in group I than in group II (1.65 ± 0.61 mm; p = 0.036) and the control group (1.72 ± 0.49 mm; p = 0.019). However, there were no significant differences between group II and the control group in the mean thickness of subcutaneous scar tissues (p = 1.000). The findings of this study indicate that the subcutaneous approximation suture is effective for preventing excessive scar tissue formation in the supratip area after rhinoplasty in rabbits. Further clinical studies are needed to determine its efficacy in humans.
    No preview · Article · Jul 2012 · American Journal of Rhinology and Allergy
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    ABSTRACT: It is well known that the nasal cavity and paranasal sinuses affect the acoustic characteristics of the voice as resonators. Any expansion in nasal valve area, the narrowest segment of the nasal cavity, affects the nasal resistance and therefore has the potential to alter the nasalance. The aim of this study was to investigate the effect of nasal valve changes on nasalance of the voice by using an external nasal dilator strip that widens the nasal valve area. Before-and-after study. Tertiary university hospital. Healthy volunteer subjects who had no nasal or voice-related complaints were enrolled in the study. All subjects underwent acoustic rhinometry and nasometry before and while wearing a commercially available external nasal dilator strip. The data with and without the nasal strip were compared. Twenty-five subjects were enrolled in the study. After the application of nasal strips, statistically significant increases were observed in the minimal cross-sectional area of the nasal valve. However, there were no significant changes in the nasalance measurements. Despite increasing the nasal valve area, application of the nasal strips did not cause any significant change in nasalance scores in healthy subjects, showing no relationship between the nasal valve and nasalance of the voice.
    Preview · Article · Feb 2012 · Otolaryngology Head and Neck Surgery
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    Sergul Ulus · Fuat Tosun · Abdullah Durmaz · Mustafa Gerek · Serdar Ulus
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    ABSTRACT: Background Computed tomography (CT), a standard diagnostic technique used to evaluate the extent of the sinus disease, fails to show bone involvement in patients with sinusitis. Bone scintigraphy is the gold standard procedure for detecting the bone involvement. Osteitis may be one of the reasons for discrepancies between extent of the disease as evaluated by CT and symptom scores. The aim of the study was to determine whether or not nuclear scintigraphy is useful in the diagnosis and management of acute, complicated acute and chronic sinusitis. Methods Forty patients with sinusitis were involved (9 acute, 4 complicated acute, 27 chronic sinusitis). 20 of the chronic sinusitis patients were with nasal polyps. All patients were evaluated with CT and SPECT (Single-photon emission tomography). 99Technetium-methylenediphosphate (99Tc-MDP) was administered for scintigraphic examination of the skull. Abnormal patterns of increased radionuclide uptake were identified and subjectively described. The mucosal involvement of sinusitis graded on Lund-Mackay Scale (LMS) was compared to degree of bone involvement evaluated by SPECT. Results While, SPECT uptakes were negative (mean uptake index is less than about 2.5) in acute sinusitis, it's highly positive (mean uptake index is more than about 4) in complicated acute sinusitis. In group of chronic sinusitis, a positive correlation between the SPECT uptakes and LMS grade was found (P < 0.05). Conclusions In our view, the bone involvement as evaluated by SPECT correlates with the stage of chronic sinusitis. Poorer subjective response was observed in patients with positive SPECT. The clinical value of scintigraphy, is limited to special indications.
    Preview · Article · Feb 2012 · World Allergy Organization Journal
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    Hakan Birkent · Abdullah Durmaz · Omer Karakoc · Turan Ilica · Mustafa Gerek
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    ABSTRACT: Congenital clefts of the larynx are rare and usually found dorsally. An anterior or ventral cleft of the larynx is extremely rare. Only a few patients with this defect have been reported in the literature. The purpose of this paper is to present a patient having an anterior and posterior laryngeal cleft together. A 20-year-old man presented with a history of dysphonia since childhood. He did not report symptoms of swallowing or respiration, and had no history of neck trauma. Findings of videolaryngoscopy showed a grossly abnormal larynx. The anterior commissure was wider than normal, and the vocal folds did not show a fusion anteriorly. There was an interarytenoid cleft posteriorly. A neck CT with 3D reconstruction demonstrated a ventral cleft or nonfusion of the thyroid cartilage with a posterior cricoid cleft. Barium swallow study was in normal limits. Since the patient did not have any problem with swallowing or respiration, no surgical intervention was planned, and the patient was put on speech therapy, which revealed improvement in voice. To our knowledge, this is the first case of a combined laryngeal cleft. The diagnosis is established by the clinical symptoms, endoscopic evaluation, and radiographic examinations including 3D and barium studies.
    Full-text · Article · Jan 2012 · Archives of Oto-Rhino-Laryngology
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    ABSTRACT: The external branch of the superior laryngeal nerve gives off many branches above the upper pole of the thyroid gland. Differentiating the branch innervating the cricothyroid muscle from the others may be important during surgery. Therefore, we aimed to demonstrate the branching pattern of this nerve in detail. In 34 human cadavers (59 sides), branches of the nerve were exposed and measurements related to them and neighboring structures were made. A cricothyroidal branch was present on all sides. This branch pierced the inferior pharyngeal constrictor muscle 3.9-17.6 mm above, 3.1-9.9 mm below, or at the level of the upper pole of the thyroid gland. On all sides, the nerve provided one or two thyroidal branches. The thyroidal branch was generally thinner than the cricothyroidal branch. But they were equal in size on three (5%) sides. The external laryngeal nerve provided two or three pharyngeal branches on all sides. These branches arose from the nerve 3.5-12.7 mm from the upper pole of the thyroid gland. Although the branch was generally thinner than the cricothyroidal branch, both branches were equal on four (6.7%) sides. Two cardiac branches were observed on two (3.3%) left sides. In conclusion, the cricothyroidal branch was generally thicker than the other branches. But on seven (11.8%) sides, thyroidal or pharyngeal branches and the cricothyroidal branch were equal in size. These data may be important during surgery as the surgeon may confuse the cricothyroidal branch with other branches of the external laryngeal nerve.
    Full-text · Article · Jan 2012 · Clinical Anatomy
  • H Yaman · A Durmaz · H H Arslan · A Ozcan · S Karahatay · M Gerek
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    ABSTRACT: The aim of the study was to evaluate the clinical features and treatment outcomes of patients with a thyroglossal duct cyst (TGDC) or fistula. The records of 49 patients (9 female, 40 male; mean age: 23.16 +/- 1.13 years; range 6 to 56 years) operated on between January 1995 and July 2009 were reviewed retrospectively. Patient's age, sex, duration of symptoms, clinical features, pre-operative diagnostic tests, treatment, histopathologic diagnosis, and post-operative complications were noted. All patients underwent the Sistrunk procedure. Fifteen patients (30.6%) were < or = 20 years old, while 3 (6.1%) patients were 40 years old at the time of operation. There was cyst formation in 26 patients (53.1%) and fistula formation in 23 patients (46.9%). The lesions of 41 patients (83.7%) were located in the midline, while the lesions of 8 patients (16.3%) were located in the paramedian neck (5 left side, 3 right side). The most common presenting symptoms were painless mass in the midline of the neck and recurrent suppuration of fistula formation. Neck ultrasonography (USG) was the most common pre-operative diagnostic procedure and was performed on all patients with cyst formations. There were no major complications postoperatively. There was recurrence in only one patient after the Sistrunk procedure. One patient was incidentally diagnosed with thyroid papillary carcinoma after histopathological examination. A TGDC is the most common congenital mass in the neck and is usually located midline. USG is suggested for a clinically suspected TGDC. The Sistrunk procedure is a safe and successful technique with low complication and recurrence rates. Even though carcinomas arising in TGDCs are uncommon, histopathological examination must be routinely performed to confirm the diagnosis and rule out malignancy.
    No preview · Article · Dec 2011 · B-ENT
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    ABSTRACT: Isolated hypermobile tongue is extremely rare. We present a case of isolated hypermobile tongue that caused several life-threatening airway obstructions during sleep. The tongue could reach to the nasopharynx and clear and moisten the nasopharynx by its movement.
    No preview · Article · Jul 2011 · The Journal of craniofacial surgery
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    ABSTRACT: We present the anatomic and cadaveric foundations for novel modifications of the occipital galeopericranial flap for reconstruction of ventral skull base defects. Anatomic description. Using cadaveric dissections and measurements, we investigated the feasibility of transposing pedicled occipital galeopericranial flaps into the nasal cavity and skull base. Two fresh and five preserved human specimens were dissected. Pedicled occipital flaps were transposed into the nasal cavity via a transparapharyngeal-transpterygoid corridor into the nasopharynx. It was demonstrated that the pedicled occipital galeopericranial flap reaches the anterior skull base. Pedicled occipital flaps transposed into the nasal cavity can reach the anterior skull base and provide another option for vascularized reconstruction in selected patients.
    Full-text · Article · May 2011 · The Laryngoscope
  • Yusuf Hidir · Bilal Battal · Abdullah Durmaz · Bulent Karaman · Fuat Tosun
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    ABSTRACT: The purpose of this study was to investigate the optimum height that the sphenoid sinus ostium can be probed safely from the roof of choana in a large group of patients. The study was performed retrospectively. The 200 sphenoid ostia of the 100 patients whose thin-section computed tomography (CT) including the sphenoid sinus region, made for various reasons, were included in the study. The height of the sphenoid ostium and the skull base from the choana roof were measured on sagittal images of CT. Also, by calculating the ratio of first measurement to the second one, the location of the sphenoid ostium at the anterior wall of sphenoid sinus was determined proportionally. The mean height of the sphenoid ostium from the choana roof was 10.9 (SD, 2.3) mm (range, 5.7-21.5 mm), and the mean height of skull base along the anterior wall of sphenoid sinus from the choana roof was 21.3 (SD, 3.2) mm (range, 13.3-30.6 mm). The ratio of the first measurement to the second measurement was 0.5 (SD, 0.08) (range, 0.29-0.77). In conclusion, under endoscopic view, the sphenoid sinus ostium can be safely probed between 13.3 mm (the minimum skull base height) and 5.7 mm (the minimum sphenoid sinus ostium height) distance upward from the choana, but determining the height of the sphenoid sinus ostium preoperatively on CTs for each patient separately will increase the chance of success in probing the sphenoid sinus.
    No preview · Article · May 2011 · The Journal of craniofacial surgery

Publication Stats

226 Citations
27.22 Total Impact Points


  • 2008-2015
    • Gulhane Military Medical Academy
      • • Gülhane Military Medical Academy
      • • Department of Anatomy
      • • Department of Pathology
      Engüri, Ankara, Turkey
  • 2011
    • University of Pittsburgh
      • Department of Otolaryngology
      Pittsburgh, Pennsylvania, United States