Persistent metopic suture can mimic the skull fractures in the emergency setting?

Metopism is partially or totally persisting suture extending from the nasion to the anterior angle of the bregma. The time of physiological closure of the metopic suture varies from birth to 8 years of age. Widely accepted closuring time is approximated at 2 years of age. Although formerly reported skull studies mentioned the persistent metopic suture, it is extremely rare in clinical practice. We presented a trauma case of 43 years of age who was demonstrated radiologically to have a persisting suture. Persistent metopic suture may be misdiagnosed as a vertical traumatic skull fracture extending in the mid-line in head trauma patients. Therefore the surgeon should be aware of this anatomical condition in the primary and secondary surveillance of the traumatized patient and during surgical intervention including especially frontal craniotomy. Reconstructed tomography scan demonstrating sutural closuring status may provide additional informative value in the diagnostic sequence superior to plain X-ray in the emergency setting.

Resuscitation with modified gelatin causes higher bacterial translocation in experimental sublethal hemorrhagic shock

The effect of colloidal solutions on bacterial translocation was studied. Sublethal hemorrhagic shock was established by blood withdrawal until the mean arterial pressure fell to 40 mmHg within 15 min on 36 adult Wistar Albino rats. Resuscitation was performed using four different solutions with the same amount of blood. Group I (n = 9) 0.9% NaCl, Group II (n = 9) 10% dextran 40, Group III (n = 9) 6% hydroxyethyl starch, Group IV (n = 9) 4% modified fluid gelatin. Before resuscitation and after anesthesia blood samples were drawn to analyze pH, PCO2, PO2, SaO2, HCO3 and ABE values. Twenty-four hours after anesthesia laparotomy was performed to obtain tissue samples of the liver, spleen and mesenteric lymph nodes. Samples were cultured on EMB and blood agar media. Results were analyzed with the one-way ANOVA and Post-hoc test (Tukey's HSD). The translocated bacteria were mainly Eschericia coli and three grew in Group I, two in Group II, three in Group III and six in Group IV. Although there was a trend in difference in bacterial translocation rates among groups, statistical analyses revealed no difference among groups (p < 0.05). It can be concluded that resuscitation with modified gelatin causes higher bacterial translocation in an experimental sublethal hemorrhagic shock model.

Effect of teicoplanin and G-CSF on survival in experimental MRSA pneumonia in neutropenic mice

AIM

To evaluate the effects of Teicoplanin and/or Granulocyte-Colony Stimulating Factor (G-CSF) on survival in an experimental model of MRSA pneumonia.

MATERIAL AND METHOD

Seventy five Swiss Albino mice weighing 35 gr (32-43) were used. 50 microl of clinical isolate of MRSA (3 x 10(8) CFU/ml in saline solution) was administered by tracheal puncture to neutropenic mice. Neutropenia was achieved by using Cyclophosphamide 200 mg per kg intraperitoneally. The groups were consisted of tracheal puncture control in neutropenic mice (group 1) (n = 15), pneumonia in neutropenic mice (group II) (n = 15), Teicoplanin therapy for pneumonia in neutropenic mice (group III) (n = 15), G-CSF therapy for pneumonia in neutropenic mice (group IV) (n = 15), Teicoplanin and G-CSF combined therapy for pneumonia in neutropenic mice (group V) (n = 15). Differences in the survival rates within 72 hours among the groups, microbiological analysis of various tissue samples were accomplished and white blood cell counts were obtained. Kaplan-Meier statistics was used for survival analysis. Subgroup comparisons were done by using Breslow statistics.

RESULTS

Teicoplanin therapy increased the survival rate (p = 0.0001) whereas G-CSF therapy did not in comparison to other groups. Teicoplanin and G-CSF combination therapy improved survival rate when compared with groups II, III, IV (p = 0.0001, p = 0.003, p = 0.0001, respectively).

CONCLUSION

Teicoplanin and G-CSF combination therapy seems effective in reducing mortality rates in MRSA pneumonia in an experimental setting. Further animal and clinical studies must be done to achieve success in the treatment of nosocomial MRSA pneumonia.

Effects of systemic and intraperitoneal chemotherapy on bacterial translocation and peritoneal defence mechanisms

Background

The aim of this study was to evaluate the effects of intraperitoneal and systemic chemotherapy on peritoneal defence mechanisms and bacterial translocation.

Methods

Four groups of adult male Wistar Albino rats (n = 10) were used in the study. The groups consisted of intraperitoneal chemotherapy (5-fluorouracil 20 mg kg−1 day−1 for 3 days), systemic chemotherapy (5-fluorouracil 20 mg kg−1 day−1 for 3 days) and their controls (systemic and intraperitoneal isotonic saline solution). Eight hours after the last dose of chemotherapy 10 ml sodium caseinate was applied intraperitoneally and 16 h later laparotomy was done under sterile conditions. During laparotomy 10 ml phosphate-buffered saline was applied and approximately 8 ml of this solution was collected. Phagocytic activity, bactericidal activity, peritoneal total cell numbers and morphology, peripheral blood leucocyte count and bacterial translocation were studied in this peritoneal solution. Tissue samples of mesenteric lymph node, liver, spleen and caecum were taken and homogenized for culturing. Statistical analyses were done with Student's t test for independent samples.

Results

In the systemic chemotherapy group phagocytic activity (36 versus 52 per cent in control) and bactericidal activity (decreased in seven versus two in control) were significantly decreased. Peripheral and peritoneal leucocyte numbers were also decreased in the systemic chemotherapy group. Peritoneal cell morphology was not affected. Bacterial translocation occurred in mesenteric lymph nodes of five rats in this group. Intraperitoneal chemotherapy significantly decreased the phagocytic activity (33 versus 56 per cent in control). Peripheral and peritoneal leucocyte numbers were also decreased but the bactericidal activity and peritoneal cell morphology were not affected. In contrast to the systemic chemotherapy group, bacterial translocation was not detected.

Conclusion

Systemic chemotherapy caused bacterial translocation. Both systemic and intraperitoneal chemotherapy have detrimental effects on peritoneal defence mechanisms under experimental conditions.

The effect of lidocaine/prilocaine cream on an experimental wound healing model

The effects of lidocaine/prilocaine cream on wound healing were evaluated in this study. An incisional wound model on abdominal wall was performed on mice. A full thickness skin incision 2 cm in length was performed then it was sutured primarily with 4/0 polypropylene. In group I (n = 10) only suturing was done (control group), in group II (n = 10) lidocaine cream was applied after suturing on wound site and it was repeated for 6 days (twice in a day), in group III (n = 10) lidocaine/prilocaine cream was applied topically after suturing and repeated 6 days (twice in a day). At day 7, incisions were excised for evaluating tensile strength and 5-hydroxyproline (5-HP) values. Tensile strength values were lowest in control group and highest in lidocaine/prilocaine treatment group. 5-HP values were also expressed the same results. Both tensile strength and 5-HP values increased significantly in treatment groups in regard to the control (p < 0.05). It was concluded that lidocaine/prilocaine cream as topical anaesthetic agent had no adverse effect in an incisional wound model, furthermore it may have some beneficial effects on wound healing which remains to be evaluated and it can be used safely in day-to-day emergency practices.

Surgeons' attitudes toward HIV/AIDS in Turkey

Currently HIV/AIDS is one of the most difficult challenges for health care professionals. As primary medical care providers, attitudes of the physicians towards HIV/AIDS are of utmost significance. The aim of this research is to determine the attitudes of the surgeons towards HIV/AIDS in their working environment. Data were collected from a self-administered questionnaire given to 128 surgeons. Results revealed that gender, age and professional experience are not significant. This study demonstrated that doctors are worried about contracting HIV/AIDS from the patients. In some circumstances doctors' attitudes, are not clear which may lead to some ethical problems. It is concluded that doctors overestimate the risks and they need special education about HIV/AIDS, as well as professional help to handle their attitudes toward HIV/AIDS.

The effect of GM-CSF (granulocyte macrophage colony stimulating factor) on doxorubicin induced tissue necrosis and wound healing

PURPOSE

The effect of GM-CSF (granulocyte macrophage-colony stimulating factor) on tissue necrosis and ulceration induced with doxorubicin extravasation was studied.

MATERIALS AND METHODS

Adult Wistar-Albino rats (n=36) were used in the study. Doxorubicin (0.4mg/300 g) was applied subcutaneously to abdominal wall. In group I (n=18), half hours after doxorubicin injection, GM-CSF 6 microg/300 mg was applied subcutaneously to the same localization. In group II (n = 18) same amount of physiologic saline (0.5 ml) were given subcutaneously to the injection site (as vehicle control groups). Group II and I were examined for induration or ulceration on 7th and 21st day. After evaluating the lesions, the injection sites were excised. Hydroxyproline (5-HP) values of dry tissue samples were calculated and histopathologic examination was done.

RESULTS

At day seven there were four and eight ulceration in groups I and II, while there were four and 14 ulceration in the second evaluation at day 21st (p<0.05). 5-HP values of the groups were as follows. 97.43+/-20.39 in group land 91.34+/-22.26 in group II. Although there was an increase in epithelization, eosinophil and lymphocyte infiltration and mast cell number in group I in histopathologic examinations only the increase in angiogenesis in group I was found to be statistically significant (p<0.05).

CONCLUSION

It can be concluded that GM-CSF may have beneficial effect in the treatment of doxorubicin induced tissue necrosis.

Effects of CO2 insufflation and laparotomy on wound healing in mice

BACKGROUND

The aim of the present study was to evaluate the effects of laparotomy and CO2 insufflation on wound healing in a murine incisional wound healing model.

METHODS

Seventy-two male Swiss Albino mice were randomly allocated into three groups of control, laparotomy and CO2 insufflation. A transverse skin incision of 15 mm was made in the dorsum of each mouse, and four interrupted mattress sutures with 4.0 polypropylene thread were laid for wound closure. A median laparotomy was performed in the laparotomy group. CO2 insufflation was performed with an intra-abdominal pressure of 9 mmHg. The retained gas was evacuated from the abdominal cavity at the end of a 60-min period. Mice were killed on the 3rd, 7th and 15th postoperative days. The wound tensile strength and 5-hydroxyproline concentration in the wound tissue were measured.

RESULTS

Tensile strength of the incised skin increased as the post-incision period progressed. There was no significant difference between the tensile strengths of the incised skin of control, laparotomy and CO2 insufflation groups throughout the observation period. The skin 5-hydroxyproline concentrations of all groups were not significantly different at the 3rd postoperative day. But laparotomy and CO2 insufflation groups had lower 5-hydroxyproline concentrations at the 7th and 15th postoperative days, when compared to controls (P < 0.02 for 7th and 15th days).

CONCLUSION

CO2 insufflation and laparotomy reduce the 5-hydroxyproline concentration of the wound, suggesting a diminished wound healing capacity.

Train-pedestrian accidents

The aim of this study was to evaluate the injury pattern, morbidity, and mortality in pedestrians involved in train accidents. The study was performed in the Hacettepe University School of Medicine, Turkey. Hospital records of 41 cases who were hit by train between the period of 1985-97 were evaluated. Age, gender, mechanism of injury (falling from train, hit by train), suicide attempts, pre-existing illnesses, RTS (Revised Trauma Score) and mortality were evaluated. Sixty-eight per cent (n = 28) of the victims were male. The mean age was 32 (9-72) years. Fifty-nine per cent of the victims had fallen from the train. The rate of suicide attempt was 22% (n = 9). The mean RTS was 10+/-3.6. Survivors had better RTS (11+/-2) than nonsurvivors (3.5+/-2.5) (p < 0.0001, 95% CI = 6.0-9.5). Extremity fractures and lower extremity amputations were frequently encountered. The mortality rate was 17%. The mortality rate was high in victims who were hit by the train (p = 0.00013). Suicide attempts carry a high mortality rate (p = 0.0001). Six mortalities were seen in nine documented suicide attempts. It is concluded that train-pedestrian injuries represent a different type of trauma. The mortality rate in suicide attempts is high. RTS lower than 11 and being hit by train are associated with high mortality.

Spontaneous hepatic rupture in pregnancy

The HELLP-syndrome (haemolysis, elevated liver enzymes, low platelets) is associated with pre-eclampsia and may cause subcapsular liver haematomas. When hepatic rupture occurs the mortality of mother and unborn is high. Rupture remains a surgical emergency with control of bleeding based on trauma principles. We report a case and discuss the diagnosis and management.

Emergency department information: does it effect patients' perception and satisfaction about the care given in an emergency department?

The aim of this study was to find out if informing the patients about the facts of an emergency department (ED) on arrival influences their behaviour and satisfaction about the care given in the ED. For 5 days an information form was distributed on arrival to all patients visiting the ED and a questionnaire directed at all patients when leaving the ED. For a former 3 days the same questionnaire directed at the patients was distributed without giving them the information form. This form contained information about how the ED functions, how long and why the patients wait, and which patients are taken care of first. The patients who were not given the information form served as the control group; the patients who were given an information form but did not read it were also included in the same control group. Questionnaires of the informed group and the control group were compared. A total of 397 patients were given a questionnaire; 288 of them were given an information form and 109 did not receive a form. The number of the patients who read the information form was 178 and the rest (219 patients) served as controls. The informed group was more satisfied about the care given to them (p = 0.1), the total time spent in the ED (p = 0.3), and the information given to them (p = 0.1). More patients in the informed group stated that they would prefer this ED next time or recommend it to others (p = 0.02). The overall degree in satisfaction of the informed patients was better (p = 0.03). The differences in the overall satisfaction and preference of this ED's parameters were statistically significant, the other parameters were not so significant. These results proved that giving general information to patients visiting the ED can influence the degree of their satisfaction.

Factors effecting mortality in urban vertical free falls: evaluation of 180 cases

AIM

The aim of this retrospective study was to evaluate the factors on mortality in urban free vertical falls.

PATIENTS AND METHODS

A total of 180 urban vertical free fall victims who survived transport to the emergency room between the period of 1980-1998 were evaluated. Minor bruises, abrasions, haematomas, and soft tissue injuries were not encountered. Serious injuries such as bone fractures, liver lacerations, epi-subdural haematomas, haemothorax, haemomediastinum, retroperitoneal haematomas were evaluated.

RESULTS

Of the total, 23% (n = 41) of patients were female and 73% (n = 139) were male. The mean age was 22.3 years (4-75 years). Extremity fractures were found in 6.7% (n = 12), cranial trauma in 14.4% (n = 26), thoracic trauma in 2.2% (n = 4) retroperitoneal trauma in 2.8% (n = 5), vertebral column trauma in 1.7% (n = 3) of cases. The overall number of the pathologies was 59. In-hospital mortality was 8.9% (n = 16). The injury severity scores (ISSs) of non-survivors and survivors were 33 +/- 4, and 5 +/- 0.6, respectively (P = 0.0001). The heights fallen were 8.6 +/- 2.3 m for non-survivors and 5.2 +/- 0.2 m for survivors (P = 0.022). The mean ages of non-survivors and survivors were 41.6 +/- 5.9 years and 20.4 +/- 1.2 years, respectively (P = 0.003). Serious cranial trauma was found in 68.7% (n = 11) and 9.1% (n = 5) of non-survivors and survivors, respectively (P = 0.0001). Extremity trauma was encountered in 31.2% (n = 5) and 4.2% (n = 7) of non-survivors and survivors, respectively (P = 0.0015). The ISSs were 6.8 +/- 1.0 and 8.9 +/- 1.1 for cases under the age of 6 years and others, respectively (P = 0.15). Using logistic regression analysis, ISS, height and age were found to be significant factors in mortality.

CONCLUSION

Vertical deceleration injury represents a distinct form of trauma. With the results of this study, it can be concluded that ISS, height and age are significant factors in determining the severity of trauma.

Effects of laparotomy, and carbon dioxide and air pneumoperitoneum, on cellular immunity and peritoneal host defences in rats

OBJECTIVE

To assess the effects of laparotomy, and insufflation of carbon dioxide and air, on the immune system in rats.

DESIGN

Randomised laboratory study.

SETTING

Teaching hospital, Turkey.

ANIMALS

77 Wistar rats randomly allocated to 2 groups one of which was sensitised with dinitrofluorobenzene (DNFB, n = 43) and one of which was not (n = 34).

INTERVENTIONS

The DNFB group was sensitised and subdivided into control (n = 8), laparotomy alone (n = 7), and insufflation with carbon dioxide (CO2) for 30 and 60 mins (n = 7 in each) or room air for 30 and 60 mins (n = 7 in each). A week later DNFB was reapplied to the ears. In the group not sensitised with DNFB the animals were subdivided similarly, the corresponding numbers in each group being, 6, 6, 6, 6, 5, and 5.

MAIN OUTCOME MEASURES

Delayed type hypersensitivity (DTH) measured by ear swelling in the DNFB group, and peritoneal bactericidal activity, total free peritoneal cell counts (TPC), and cell types in the non-sensitised group.

RESULTS

There were significant differences in the degree of ear swelling in the DNFB group between control and laparotomy groups (p = 0.0001) and between control and both insufflations of air (p = 0.002 and p = 0.0003, respectively). In the non-sensitised group peritoneal bactericidal activity was significantly increased after 7 hours in the 60 mins air insufflation group (p = 0.04). At 24 hours there were no differences among the groups. TPC were not affected. The number of peritoneal polymorphonuclear leucocytes (PMN) was significantly higher in the laparotomy alone group than in the control or any of the insufflation groups (p < 0.05).

CONCLUSIONS

Laparotomy and air insufflation depressed cell-mediated immunity. Peritoneal bactericidal activity was affected only after 60 minutes of air insufflation.

The effects of G-CSF treatment and starvation on bacterial translocation in hemorrhagic shock

BACKGROUND

Bacterial translocation is thought to be responsible for infectious complications after hemorrhagic shock. The aim of this study is to investigate the effects of granulocyte colony-stimulating factor (G-CSF) treatment on bacterial translocation in starved or fed animals subjected to hemorrhagic shock.

MATERIALS AND METHODS

Fifty Wistar albino rats (200-275 g) were divided into six groups such as naive control (n = 7), G-CSF treatment (n = 7), hemorrhagic shock in starved rats (n = 9), hemorrhagic shock in fed rats (n = 9), G-CSF treatment 24 h before hemorrhagic shock in starved rats (n = 9), and G-CSF treatment 20 min after hemorrhagic shock in fed rats (n = 9). Hemorrhagic shock was induced by withdrawal of 2.1 ml/100 g blood via a carotid arterial cannulae placed under sodium pentobarbital anesthesia. Twenty-four hours later, mesenteric lymph nodes, liver, spleen, and peripheral blood samples were evaluated by using a quantitative microbiological technique and the numbers of colony-forming units were compared between groups.

RESULTS

No bacteria was detected in samples from naive controls or G-CSF-treated unshocked rats. In animals subjected to hemorrhage, Escherichia coli was the predominant pathogen together with Streptococcus faecalis, Pseudomonas, and Lactobacillus species. In this model, starvation augmented the magnitude of bacterial translocation while G-CSF treatment has virtually abolished it.

CONCLUSION

Under experimental conditions, preshock starvation increases gut-derived bacterial translocation and administration of G-CSF before or after hemorrhagic insult significantly reduces it.

Factors that may increase morbidity in a model of intra-abdominal contamination caused by gallstones lost in the peritoneal cavity

OBJECTIVE

To assess the effect of intraperitoneal gallstones with and without Escherichia coli and sterile bile on the incidence of intraperitoneal complications in mice.

DESIGN

Prospective randomised study.

SETTING

Teaching hospital, Turkey.

MATERIAL

180 Swiss albino mice in five groups, n = 20 in the control group, and n = 40 in each of the experimental groups.

INTERVENTIONS

Group A laparotomy alone (controls); group B, laparotomy amd intraperitoneal instillation of E. coli 4 x 10(6) 0.1 ml; group C, laparotomy and insertion of sterilised gallstones; group D, laparotomy, insertion of gallstones and instillation of E. coli 4 x 10(6) 0.1 ml; and group E, laparotomy, insertion of gallstones, and instillation of E. coli 4 x 10(6) 0.1 ml and sterile bile 0.1 ml. A quarter of each group was killed after 1, 2, 4, and 8 weeks.

MAIN OUTCOME MEASURES

Intra-peritoneal abscesses, adhesions, perforations, fistula, or obstruction.

RESULTS

No mice died. Adhesions were found in 3(15%), 7(18%), 30(75%), 25(63%), and 24(60%) in the five groups, respectively. No mice in groups A, B, or C developed an abscess, but 8 did in each of groups D and E (20%). One mouse in group D developed obstruction. Logistic regression showed that abscess formation was significantly increased by the addition of gallstones and E. coli to the peritoneal cavity (p < 0.001) but the addition of bile had no effect. Gallstones increased the rate of adhesions more than nine fold (p < 0.001) but E. coli with or without bile had no effect (p = 0.75).

CONCLUSIONS

Free gallstones within the peritoneal cavity with or without E. coli or sterile bile, or both, increased the rate of formation of both abscesses and adhesions in mice. These results suggest that efforts should be made retrieve gallstones that are dropped into the peritoneal cavity during laparoscopic cholecystectomy, particularly in patients with acute cholecystitis.

Effect of omentectomy on peritoneal defence mechanisms in rats

OBJECTIVE

To assess the effect of omentectomy on peritoneal defence mechanisms in rats.

DESIGN

Randomised study.

MATERIAL

Sixty Wistar Albino rats.

INTERVENTIONS

Rats were divided in three groups of 20. All rats underwent midline laparotomy and 10 rats in each group had omentectomy. Samples were taken two hours (early period) and 30 days (late period) after omentectomy.

MAIN OUTCOME MEASURES

Effect of omentectomy on bactericidal activity of peritoneal fluid (PBA), chemotactic indices (CI) of polymorphonuclear leucocytes (PMNL), phagocytic activity of PMNL in the peritoneal fluid (PHA), total cell counts, and cell types of peritoneal washing fluid.

RESULTS

In the early period omentectomy reduced total cell counts from 3440 (1400-4800) x 10(6)/10 ml to 1480 (800-2080) x 10(6)/10 ml (p = 0.0022), and the CI of PMNL from 2.86 (2.32-4.02) to 1.43 (1.29-1.77) (p = 0.0002), and increased the PHA from 11.9 (8.3-17) to 17 (16-19) (p = 0.0006). The PBA was not significantly altered. The proportion of macrophages decreased (p = 0.0001), while the proportion of lymphocytes increased in the peritoneal fluid (p = 0.0002). In the late period total cell counts in the control and omentectomy groups were 3440 (1400-4800) x 10(6) and 3160 (1040-5120) x 10(6)/10 ml fluid, respectively (p = 0.52). Omentectomy reduced the CI of PMNL from 2.86 (2.32-4.02) to 2.01 (1.82-1.49) (p = 0.0003). The difference between the proportion of PHA of either group was not significant (p = 0.06). PBA in the control and omentectomy groups was 99.03 (70-100) and 99.48 (71.5-100), respectively (p = 0.97). Although the total cell count in the peritoneal fluid did not differ, the proportion of macrophages decreased (p = 0.0003) while the proportion of lymphocytes increased (p = 0.0002). The proportion of PMNL did not change in either of the experimental settings.

CONCLUSIONS

The omentum has an important role in local peritoneal defence mechanisms in experimental conditions. Its removal may effect some of these mechanisms adversely.

The role of HBV DNA and liver histopathology in HBsAg carriers

BACKGROUND/AIMS

In this study, we evaluated the association among serum transaminase values, seropositivity of HBV DNA and liver histopathology of patients with positive HBsAg and HBe antibodies.

METHODOLOGY

Thirty-five patients were placed in two groups according to their serum transaminase values. Patients with normal transaminase values were evaluated in the first group. The patients with above normal transaminase values were subjected in the second group.

RESULTS

In the first group of patients with normal transaminase values, biopsy-proven moderate or severe chronic hepatitis was not observed. HBV DNA seropositivity was 53.3% in this group. Forty-five percent of the patients with above normal transaminase values had moderate chronic hepatitis and seropositivity for HBV DNA in this group was 55%. Our results supported the association between transaminase values and liver pathology, but no statistically significant association was shown between seropositivity of HBV DNA and liver pathology.

CONCLUSION

There is much to be studied to understand the function of HBV DNA in the follow up of HBsAg carriers, and liver biopsy has to be used routinely in the follow up of asymptomatic carriers when they happen to have high transaminase values.