Protective effects of pentoxifylline in small intestine after ischemia-reperfusion

Objective

This study was performed to determine the healing effects of pentoxifylline on molecular responses and protection against severe ischemic damage in the small intestine.

Methods

Thirty-six Wistar albino rats were divided into six groups. The superior mesenteric artery was clamped for 120 minutes, and reperfusion was performed for 60 minutes. Saline (0.4 mL), pentoxifylline (1 mg/kg), and pentoxifylline (10 mg/kg) were intraperitoneally administered to the rats in the C₁, P₁, and P₃ groups, respectively, 60 minutes before ischemia and to the rats in the C₂, P₂, and P₄ groups, respectively, during reperfusion onset. Malondialdehyde, myeloperoxidase, tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6 in serum and tissue were measured by enzyme-linked immunosorbent assay. Intestinal ischemic injury was histopathologically evaluated by the Chiu score and immunohistochemical staining.

Results

All serum and tissue molecular responses were significantly blunted in the pentoxifylline-treated groups compared with the controls. Significant improvement in ischemic damage was demonstrated in the pentoxifylline-treated groups by histological grading and immunohistochemical scoring.

Conclusions

The protective effects of pentoxifylline were confirmed by molecular responses and histopathological examination.

Importance of knowledge of the management of traumatic dental injuries in emergency departments

BACKGROUND

Hospital emergency departments (EDs) are confronted with managing dental emergencies of both traumatic and non-traumatic origin. However, the literature suggests inadequate knowledge of the management of traumatic dental injuries (TDIs) among medical professionals. The aim of this study was to investigate the knowledge and attitudes regarding management of TDIs among Istanbul ED physicians.

METHODS

Surveys were distributed to emergency departments (ED) directors and their physicians. The survey contained questions about their characteristics and tested their knowledge of managing dental trauma.

RESULTS

A total of 126 surveys (13 ED directors and 113 physicians) were returned and included in the analysis. ED physician's knowledge of the appropriate management of crown fractures and avulsion was generally good (p=0.221), but poor for luxation injuries (p=0.0001). Physicians were more likely to have a better knowledge about permanent teeth than about primary teeth (p=0.027).

CONCLUSION

Education, monitoring, improved availability of resources, and disciplinary measures in cases of poor compliance are necessary to improve TDI management in hospitals, especially among physicians.

Comparison of contrast-enhanced CT with diffusion -weighted MRI in the Evaluation of patients with acute biliary pancreatitis

OBJECTIVE

The aim of this study was to compare contrast-enhanced computed tomography with diffusion-weighted magnetic resonance imaging in the evaluation of patients with acute biliary pancreatitis.

MATERIAL AND METHODS

Fifty-three patients diagnosed with acute biliary pancreatitis, between February 2012 and July 2015, were evaluated using diffusion-weighted magnetic resonance imaging and magnetic resonance cholangiopancreatography to explain the elevation of cholestasis enzymes and bilirubin levels at "stanbul University. Contrast-enhanced computed tomography imaging was applied within 8 h following first evaluation. Demographic data, severity of pancreatitis, pancreatic apparent diffusion coefficient, and computed tomography severity index were compared. The significance of the results was evaluated using Statistical Package for the Social Sciences 21.0 program.

RESULTS

Median age was 53.39 (22-90) years in these 53 patients (26 were males and 27 were females). The mean Ranson criterion was 0.96 (0-4) and mean hospitalization duration was 16.02 (3-100) days. Twenty-eight patients were evaluated to have mild acute pancreatitis, whereas 16 were moderately severe and nine were severe based on the Revised Atlanta Classification. Mild pancreatitis score was 0.89, moderately severe pancreatitis score was 3.50, and severe pancreatitis score was 5.78 using the Balthazar score. Elevated C-reactive protein levels were not correlated with necrosis and the clinical severity score (p>0.05). There was no significant difference among the Balthazar score, magnetic resonance cholangiopancreatography-apparent diffusion coefficient score, and Revised Atlanta score in the evaluation of the severity of pancreatitis when the two techniques were compared. A statistically insignificant difference was found between the Balthazar score and magnetic resonance imaging results of clinically confirmed necrosis and non-necrosis patients.

CONCLUSION

It can be concluded that diffusion-weighted magnetic resonance imaging might be better than contrast-enhanced computed tomography in the diagnosis of acute pancreatitis as it avoids radiation exposure as well as the development of renal failure and pancreatitis aggravation due to the use of contrast for computed tomography. These results need to be confirmed with randomized prospective controlled studies.

What is the clinical yield of capsule endoscopy in the management of obscure bleeding in emergency service?

BACKGROUND

The aim of this study was to investigate the efficacy of capsule endoscopy (CE) performed on patients who presented to emergency room with clinically evident gastrointestinal (GI) bleeding from unknown source and were hospitalized for follow-up.

METHODS

Total of 38 patients who underwent CE and were followed-up for evaluation of clinically perceptible GI bleeding with no obvious etiology in Istanbul Medical Faculty emergency surgery department were included in the study. Patient data, which were collected between January 1, 2007 and June 1, 2015, were reviewed retrospectively.

RESULTS

Of the 38 patients included in this study, 12 (32%) patients were women and 26 (68%) were men. Average age was 55.57 years (range: 20-88 years). Nine patients were using anticoagulants. Ten patients were followed-up in intensive care, and 7 patients underwent angiography. Angioembolization was performed for 1 patient who was diagnosed as having active bleed with CE. Average erythrocyte suspension replacement was 20.7 units. Total of 13 patients underwent surgery for bleeding found with CE. Eleven (34%) patients underwent double-balloon endoscopy, during which 5 patients were treated with cauterization and sclerotherapy was performed on 2. Four (18%) patients died during the study period: 2 died as result of bleeding from unknown source, 1 died of cholangiocarcinoma recurrence, and 1 died of anastomotic leakage. One patient was readmitted to hospital due to recurrence of bleeding. Nineteen (50%) patients were treated successfully based on CE findings. Diagnostic yield of CE was determined to be 78.9%. Average length of hospital stay was 32.68 days (range: 3-153 days).

CONCLUSION

CE is an effective tool to detect source of GI bleeding. CE should be first choice of evaluation method for patients admitted to emergency room with obscure overt GI bleeding once radiological imaging determines absence of obstruction.

The role of colorectal stent placement in the management of acute malignant obstruction

BACKGROUND

In recent decades, the use of colorectal stents for palliation or as a bridge to surgery in acute malignant colorectal obstruction has increased. We aimed to evaluate the technical and clinical efficacy, safety and clinical outcomes of endoscopic stenting for the relief of acute colorectal obstruction secondary to cancer.

METHODS

From March 2006 to December 2012, among 100 patients with acute malignant colorectal obstruction, stenting procedures were performed on 42 patients for relief of obstruction. Uncovered self-expanding metal stents (SEMS) were placed endoscopically under fluoroscopic guidance in all patients. Using the patient database, a review was conducted to determine the effectiveness of the procedure and the short- and long-term complications.

RESULTS

Stent placement was technically successful in 39/42 (92.8%) and clinically successful in 38/42 (90.4%) patients. Sixteen patients later underwent an elective surgical resection, and in 26 patients with metastatic disease or comorbidity, stent placement was palliative. Complications occurred in 10 (23.8%) patients, and the most common was tenesmus (n=3). Migration, bleeding, and recto-sigmoid perforation occurred in two patients each. Stent obstruction due to fecal impaction was seen in one case.

CONCLUSION

Stent placement for colorectal obstruction is an effective and relatively safe procedure, with minor complications. It not only allows subsequent elective resection, but is also definitive for palliative treatment in patients with obstructive colorectal cancer.

Falling television related child injuries in Turkey: 10-year experience

BACKGROUND

We reviewed retrospectively TV-related injuries to determine the risk factors, type of injuries, and operative intervention(s) required in children injured by falling TVs.

METHODS

This was a retrospective descriptive study conducted on 42 pediatric patients who were admitted to Istanbul University, Istanbul Medical Faculty, Emergency Surgery Department. Case notes included all demographic and injury details, TV and TV-related furniture type, mechanism of injury, Pediatric Trauma Score (PTS), Pediatric Glasgow Coma Scale (PGCS), length of hospital stay, need for intensive care unit assessments, and management plans.

RESULTS

More than 65% of the children were aged 1 to 3 years. The injury rate was higher for boys (66.7%) than girls (33.3%). Of the 42 patients identified, 17 (40.5%) sustained only head injuries, with almost half of these having a definite traumatic brain injury; 6 (14.3%) had only thoracic injury, and 4 (9.5%) had only limb injury. The PGCS ranged from 3 to 15, with a mean of 7. The PTS ranged from -6 to 12, with a mean of 9. Five children (11.9%), all aged 2 years or younger, died in the hospital as a result of the TV-related injury, all sustaining head and thorax injuries, which are reflected in a significantly lower PTS and lower PGCS on admission compared with older children. TV falls on to children often occur because of unstable supports, with dressers and shelves being the most common. The most common mechanism of injury (71.4%) among all age groups was fall/tipping of furniture. Pulling the furniture onto oneself (19%) was the second most frequent mechanism of injury.

CONCLUSION

Injuries related to TV falls can lead to significant morbidity and mortality in children. As they are preventable injuries, restricted activity and improved supervision of children around the TV can potentially lead to fewer incidences.

[Evaluation of "life-threatening" definition and negligence in children treated in the emergency surgery service burn unit (from the viewpoint of forensic medicine)]

BACKGROUND

The aim of this study is to outline the sociodemographic and traumatic characteristics of children who were referred to the Burn Unit of Emergency Service with burn injuries, to discuss the doctors' approach to these cases, and to compare the prognosis of patient groups with and without life-threat.

METHODS

This epidemiological study was carried out between 14 October 2004 and 31 December 2006 and included a total of 134 pediatric patients aged between 0-18 years. A semi-structured questionnaire form was designed to obtain the information from the study population. The obtained data were statistically evaluated.

RESULTS

66.2% (n=90) of the cases were male and 33.8% (n=46) were female. The mean age of the study population was 3.9+/-4.1 years and the mean percentage of burned body area was 22.47+/-17.37. The main cause of burn was scalding with hot water, with a frequency of 77.2% (n=105). When the percentage of burn area of the body was lower than 20%, the mortality was 6.3% (n=6), whereas it was 61% (n=25) when the burn area exceeded 20% of the body (p=0.0001). While the mortality was 21.0% (n=25) among the cases with first-degree burns, it was 35.3% (n=6) among those with second- and third-degree burns (p=0.189). Mortality ratio among the cases with life-threat was higher than those without life-threat, and this difference was statistically significant (p=0.033).

CONCLUSION

Extent of burn is a determinative factor for prognosis in children. Evaluation of all burn cases in children should be approached as cases of neglect/abuse; protection of these children in this manner will serve as an important practice of preventive medicine.

Femoral artery occlusion secondary to a spontaneously "migrated" hip prosthesis: case report

A 77-year-old male patient was admitted to the hospital with a worsening acute ischemia of the left lower extremity. The patient, who had a coxarthrosis and was being followed by the orthopedic clinic, had undergone a total hip prosthesis, with a revision performed at the sixth month of its placement. The physical examination revealed the absence of the femoral, popliteal and distal pulses of the left lower extremity. The left hip movements were painful and limited in external rotation posture. Doppler ultrasonography showed an acute occlusion of the left common femoral artery due to the dislocated hip prosthesis, and right-to-left femorofemoral expanded polytetrafluoroethylene graft bypass was carried out. After successful surgery and an uneventful postoperative period with palpable femoral and popliteal pulses, the patient was put on low molecular weight heparin and referred to orthopedics once the ischemia had subsided with the intervention. Case reports regarding occlusions due to migration of total hip prosthesis are rare in the literature. The emphasis of this case report is to describe one such case.

Burn and vital risk criteria in industrial accidents (as forensic medicine approach)

BACKGROUND

Burn traumas resulting from industrial accidents may generate a death risk. In such cases a forensic report should be filled up. In forensic findings, the death risk which is associated with the degree of trauma, of the victim is as important as the treatment of the subject. The aim of our research was to investigate what degree of burns causes fatality and which type of industrial accidents cause them.

METHODS

This research was done between the dates October 2004 and December 2006 with the descriptive epidemiology method by the evaluation of all data entered emergency surgical room- burn unit. The results of the study were analyzed with respect to its socio-demographic characteristics clinical findings of the type of burn and the type of the event which caused the burn. Categorical variables were assessed using Chi-square test, continuous variables were tested by Pearson's correlation.

RESULTS

For the total 128 incidents, 69.5% (n=89) were males and 30.5% (n=39) females. 28.9% (n=37) of the incidents were industrial accidents. 48.6% (n=18) of the burns were caused by boiling water, 32.4% (n=12) due to contact by flame, 10.8% (n=4) electrocution and %8.2 (n=3) due to burns by contact with chemicals. The 19.50% (n=25) of the incidents had ended up by loss of life, 80.5% (n=103) were cured and discharged. The incidents which had resulted under 20%, the mortality rate was 1.3% (n=1), the incidents which had above 20%, the mortality rate was 49.0% (n=24) (p=0.0001).

CONCLUSION

The degree of burn was found to be valuable in determining the death risk but the extent of the burned area was found to be more deterministic in assessing this particular risk.

The effect of melatonin on TNBS-induced colitis

Ulcerative colitis is a multifactorial inflammatory disease of the colon and rectum with an unknown etiology. The present study was undertaken to investigate the effect of melatonin administration on oxidative damage and apoptosis in 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis. Rats were divided into four groups as follows: Group 1 (n=8)-T-NBS colitis; Group 2 (n=8)--melatonin, 10 mg/kg/day ip, for 15 days in addition to TNBS; Group 3 (n=8)--melatonin alone, 10 mg/kg/day ip, for 15 days; and Group 4 (n=8)-isotonic saline solution, 1 ml/rat ip, for 15 days (sham control group). Colonic myeloperoxidase (MPO) activities, malondialdehyde (MDA) levels, and glutathione (GSH) levels are indicators of oxidative damage, while caspase-3 activities reveal the degree of apoptosis of the colonic tissue. In all TNBS-treated rats, colonic MPO activity and MDA levels were found to be increased significantly compared to those in the sham group. Colonic MPO activity and MDA levels were significantly lower in the melatonin treatment group compared to TNBS-treated rats. GSH levels of colonic tissues were found to be significantly lower in TNBS-treated rats compared to the sham group. Treatment with melatonin significantly increased GSH levels compared to those in TNBS-treated rats. Caspas-3 activity of colonic tissues was found to be significantly higher in TNBS-treated rats compared to the sham group. Treatment with melatonin significantly decreased caspase-3 activity compared to that in TNBS-treated rats. These results imply a reduction in mucosal damage due to anti-inflammatory and anti-apoptotic effects of melatonin.

[A different approach to trauma scoring]

BACKGROUND

We have compared the Injury Severity Score (ISS) at admission to Emergency Surgery and Trauma Center (ES&TC) with the ISS during autopsy. Cases with ISS less than 14 (defined as preventable deaths) were evaluated and the results were compared with those in other countries.

METHODS

The study was performed between January 1, 2000 and December 31, 2002 at Istanbul Medical Faculty TS&ES and the Turkish Council of Forensic Medicine. The 160 autopsies of trauma deaths which could have been performed within this three year period were evaluated.

RESULTS

The average age of trauma victims in the study was 32,9+/-15,6 (r=1-79); the majority of victims were males 78,1% (n=125). In four autopsies (3%) ISS were rated as "preventable death" (ISS < or =14). The severely injured (ISS: 16-66) patients with lower survival rates were 96% (n=155). In addition, one case (1%) had an ISS score of 75. In clinical evaluations, ISS scores were found to be between 16-66 (68%), 75 (20%, n=32), and < or =14 (12%; n=19).

CONCLUSION

Although it is widely used, difficulties in the applications of ISS still exist. Alcohol, drug, pregnancy and the presence of underlying diseases are the factors contributing to death but not being reflected by ISS. Moreover a difficulty exists in the evaluation of anatomical injuries which are not accompanied by physiological changes. ISS should be improved according to updates. In this way, evaluation of clinics' care quality and standardization of trauma centers can be done more accurately.

[Approach to the lower gastrointestinal tract bleeding in patients with normal colonoscopic findings.]

BACKGROUND

Lower gastrointestinal bleeding is a commun clinical entity. Although colonoscopic examination is the first choice for diagnosis, it may not be enough to reveal the cause of bleeding in all subjects.

METHODS

Eight patients who had massive lower gastrointestinal bleeding having normal colonoscopic findings were retrospectively evaluated at the Department of Trauma and Emergency Surgery, Istanbul University, Faculty of Medicine

RESULTS

There were 5 male and 3 female patients with mean age of 51 (28 to 82). Patients received a mean of 13 U (range 2 to 23) with transfused erythrocyte concentrates. Four patients had found to be normal during angiographic, scintigraphy or enterocylytic examinations. Angiography was diagnostic in 4 patients, and identified bleeding from ileocolic pseudoaneurisms (n= 2) branches of jejunal artery (n=2). Embolization procedure were performed in these 4 patients and 3 of them developed intestinal necrosis and underwent surgery. One did not require further treatment. Two of the patients who underwent surgery expired due to sepsis. Patients were hospitalized for a mean of 17 days (range 5 to 37).

CONCLUSION

Despite employment of all diagnostic procedures, the cause of bleeding were not detected in half of patients who had normal colonoscopic findings. If angiographic treatment is necessary, superselective arterial embolization should be performed.

Intermittent pneumatic compression in the prevention of venous thromboembolism in high-risk trauma and surgical ICU patients

BACKGROUND

Our aim was to evaluate the efficacy and safety of intermittent pneumatic compression methods (IPC) in the prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE) in high-risk patients followed in our intensive care unit (ICU) for whom anticoagulation is contraindicated due to high risk of bleeding.

MATERIALS AND METHODS

This prospective study was conducted between October 2001 and June 2002 at the Trauma and Surgical Emergency Service of Istanbul Medical Faculty. Thirty eight surgical ICU patients who used IPC devices for prophylaxis of venous thromboembolisim were evaluated retrospectively.

RESULTS

There were 27 male (71%) and 11 female patients (29%) with a mean age of 49.69 +/- 18.61 years. Their diagnoses were as follows; 21 multi-trauma, 11 major abdominal surgery, 11 severe gastrointestinal bleeding. None of the patients had manifested DVT by venous duplex scans. A leg swelling was present in one patient without evidence of DVT by duplex scans. Symptomatic and fatal pulmonary embolism were not detected. Asymptomatic pulmonary embolism was detected by spiral thorax CT examination in one patient (2.6%).

CONCLUSIONS

IPC seems to be an effective and a safe modality in preventing both DVT and PE in high-risk ICU patients with severe trauma and for those undergoing major surgery.

Seasonality in the incidence of abdominal aortic aneurysm ruptures: a review of eight years

BACKGROUND

Ruptured abdominal aortic aneurysm (RAAA) is a highly mortal entity. In recent years, the role of seasonality has been proposed in the incidence of RAAA. In this study, we sought possible correlations between monthly atmospheric pressures and the number of patients admitted with RAAA.

METHODS

Twenty-four patients who were admitted to our Trauma and Emergency Surgery Department with a diagnosis of RAAA from January 1995 to May 2003 were retrospectively evaluated. Data were collected from patient records, admission charts, hospital death certificate registry, and operating-room records. Only patients whose diagnosis of RAAA was confirmed during surgery were included. Atmospheric pressure records of Istanbul for individual months covering the study period were obtained from the Meteorology Office. The incidences of RAAA and the mean monthly atmospheric pressures were compared.

RESULTS

Most of the patients were admitted in winter months. Admissions culminated in January with six patients, at which time the mean atmospheric pressure was 765.5 mmHg. There were no admissions in May, during which the mean atmospheric pressure was 760.8 mmHg. The distribution of monthly admissions for RAAA was not statistically significant (p>0.05). The mean atmospheric pressures tended to run a higher course before the months in which increased admissions were seen.

CONCLUSION

Our findings do not corroborate the presence of a relationship between the incidence of RAAA and the atmospheric pressure.

The late outcomes of vena cava filters in the prevention of pulmonary embolism

BACKGROUND

Pulmonary embolism (PE) is the most serious complication of deep venous thrombosis (DVT) resulting in high morbidity and mortality rate. The purpose of this study is to evaluate the long-term results of vena cava filters (VCFs) placement for prevention of PE in high- risk patients.

METHODS

Between June 1999 and March 2002, at the Trauma and Surgical Emergency Service of Istanbul Medical Faculty, 15 high-risk patients who underwent placement of filters were evaluated.

RESULTS

There were eleven males (73%) and four females (27%) with mean age of 50 years (range 14 to 76). Eleven of VCFs were placed for prophylactic and four for therapeutic purposes. The indications of VCFs placement are as follows: Spinal cord injury with life-long paraplegia in eight and quadriplegia in two patients, venous thromboembolism while on anticoagulation in two patients, contraindications to anticoagulation in three patients. The mean duration of follow-up was 17 months (range 3-32 months). No patients developed DVT and recurrent DVT. No patients clinically had signs or symptoms of PE. There was one insertion site thrombosis that related to VCF complications, which resolved with medical therapy. Four patients died during the study period. Medical records revealed no evidence of PE.

CONCLUSION

Although VCF placement seems to prevent PE in high- risk patients, prospective randomized trials with larger patient groups and longer-term follow up period are necessary to evaluate efficacy and safety of VCF in prevention of PE before making definitive conclusion.

[Venous thromboembolism prophylaxis with low molecular weight heparins in polytraumatized patients in intensive care unit (extended serie)]

BACKGROUND

In our study we aimed to evaluate, retrospectively, the bleeding and the Venousthrombo Emblism (VTE) complications in trauma patients in Intensive Care Unit (ICU) under the prophylaxis of enoxaparin sodium. The results will guide us to establish a protocol for use of Enoxaparin Sodium in trauma patients. In trauma patients, Low Molecular Weight Heparine (LMWH) has better efficiency than unfractionned heparin and intermittant pneumatic compression for VTE prophylaxis.

METHODS

457 polytraumatized patients treated in ICU are included to the study group. All patients received 40 mg/day of Enoxaparin Sodium. Severity of trauma was assessed with Apache II Scoring System and bleeding diagnosed by observing a sudden drop of 2 g/dl in hemoglobin concentration and pulmonary embolism was diagnosed by a sudden change in blood gases and deterioration of the clinical outlook which was confirmed by a spiral CT scan. Statistical correlation was made by Pearson's correlation test.

RESULTS

Mean Apache II score was 13.8 with a total mortality of 41%. 42 patients (9,2%) had bleeding due to Enoxiparine Sodium prophylaxis. 12 patients (2,6%) had pulmonary embolism and 8 of them (1,7%) had died.

CONCLUSION

Verified by the literature and our study, LMWH prophylaxis significantly reduces the Pulmoner Embolism (PE) incidence in polytraumatized patients (p<0,05). On the other hand, the bleeding risk has slightly increased without showing any significance (p>0.05). Prophylaxis with LMWH is safe and efficient in polytraumatized ICU patients.

[Evaluation of severe burns managed in intensive care unit]

BACKGROUND

This study designed to evaluate the results of the patients with severe burns treated in the intensive care unit.

METHODS

Between May 1997 and May 2002, fifty-four patients who had thermal and electrical burns managed at the Intensive Care Unit of General Surgery of Istanbul University Medical Faculty.

RESULTS

Forty-five of patients were males and nine were females with mean age of 39 years. The mean hospital stay was 26 days. The mean total body surface area burns was 60%. Pseudomonas aeruginosa was detected in wound cultures at the 68% of patients. 83% of cases died. Mortality was due to sepsis in 66% of patients.

CONCLUSION

Besides early debridmant, early enteral feeding, woundcare and intensive care unit support, establishing of specific burncenters may reduce morbidity and mortality rates in severe burns.

[Our current approach in the treatment of sigmoid colon volvulus]

BACKGROUND

Our aim was to emphasize the role of endoscopic detorsion in the treatment of sigmoid colon volvulus, which we currently apply in the majority of our cases.

METHODS

The data of 37 patients were analyzed in a retrospective manner, during a 86-month period, between May 1994 and July 2001. The patients were classified into three groups. The first group consisted of 9 patients with resection and anastomosis, the second group consisted of 20 patients with Hartmann's procedure, and the third group consisted of 8 patients with endoscopic detorsion.

RESULTS

Complications were encountered in 7 patients (19%), and 3 patients (8%) died following treatment.

CONCLUSION

We favor colonic resection following endoscopic treatment. Resection should be preferred, if endoscopic detorsion is not successful or in the presence of a complication.

[Results of conservative treatment for solid abdominal organ trauma]

We analyzed 59 cases of intraabdominal solid organ injury treated at the Surgical Emergency Service of Istanbul Medical School between January 1996 and January 2001. Fifty-six of these cases suffered blunt and 3 penetrating trauma. Twenty-three cases had injuries involving the liver, 14 spleen, 5 kidney, 6 liver and spleen, 6 liver and kidney, 6 spleen and kidney and four liver and kidney. In 4 of splenic and 5 of hepatic injuries Grade IV injuries were detected. Among the cases, 21% were Grade I, 45% were Grade II, 19% were Grade III, and 15% were Grade IV. Associated injuries were: head trauma in 34 cases (57.6%--Glasgow Coma Score under 7 in 6 cases), thoracic trauma in 19 cases (32%), pelvic fracture in 6 cases (10%), vertebral compression fracture in 3 cases (5%). One patient with splenic (Grade III) and hepatic (Grade II) injury, and one patient with Grade IV splenic injury required surgery during close follow-up due to hemodynamic instability. Our failure rate for conservative treatment of solid organ injuries is 3.3%. Three patients with polytrauma in the ICU died (5% mortality rate). Conservative management in solid organ injuries is gaining more popularity every day. Our work, and current studies accept physiologic parameters in the follow-up of solid organ injuries. Conservative treatment guided with hemodynamic stability, accounts almost a 98% success rate.

Thrombolysis of Acute Arterial Occlusion with rt-PA

The use of thrombolytic agents to treat peripheral arterial occlusions is a new method. Despite its advantages, information about complications caused by the use of rt-PA and about its place in treatment is still incomplete. The aim of this study was to establish a dose range for rt-PA and to follow the patients with a protocol during and after thrombolysis. Between May 1999 to January 2000, 14 patients with symptoms of peripheral arterial occlusion came to Istanbul Medical Faculty Emergency Surgery Unit. The duration of ischaemia before their hospitalization took an average of 44 hours. (Range 3 hours-7 days). A pulse-spray catheter was directed to the thrombus under angiographic control. Bolus injection of 5 mg of rt-PA was followed by 15 minutes of interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mg of rt- PA was repeated. After angiographic control, patients having insufficient thrombolysis, received 0.05 mg/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was made to patients still having an occlusion after thrombolysis. To avoid re-occlusions, all of the patients received 1.5 mg/kg/day low molecular weight heparin (enoxaparin) for 1 week. At the end of thrombolysis, 9 patients had complete lysis. A patient, having an occlusion in superior mesenteric artery had 60% recanalisation. 2 patients (14%) having 90% stenosis, needed a balloon angioplasty besides thrombolysis, and both of them had complete reperfusion. 2 patients (14%) needed a thromboembolectomy operation due to insufficient thrombolysis. 2 patients (14%) had a minor bleeding after thrombolytic treatment. After thrombolysis, 2 patients (14%) had a stroke. There were no amputations. 1 of the patients having a stroke, died 2 days after thrombolytic treatment 1 patient died due to myocardial infarction during thrombolysis. 1 patient (7%) died due to diabetic coma on the 20th day. Acute myocardial infarction was the cause of death in 1 patient on the 25th day. In conclusion pulse spray thrombolysis with rt-PA is safe and efficient. Moreover there is a reduction in complications and need for surgical procedure. The recent problem is to find the optimum dosages for the best thrombolysis and for least complications.

[Thrombolysis of acute arterial occlusion with rt PA]

The use of thrombolytic agents to treat peripheral arterial occlusions is a new method. There have been clinical trials with Streptokinase, Urokinase and rt-PA (recombinant tissue plasminogen activator). Despite its advantages, information about complications caused by the use of rt-PA and about its place in treatment is still not complete. And there are not enough studies that are made to form a safe protocol for the use of rt-PA in the treatment of acute peripheral arterial occlusions. The aim of this study was to establish a dose range for rt-PA and to follow the patients with a protocol during and after thrombolysis. Between May 1999 to January 2000, 14 patients with symptoms of pain, poikilothermia, cyanosis and loss of function came to Istanbul Medical Faculty Emergency Surgery Unit. Bolus injection of 5 mgr of rt-PA was followed by 15 minutes of interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysis, received 0.05 mgr/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was made to patients still having an occlusion after thrombolysis. On the other hand, to avoid re-occlusions, all of the patients received 1.5 mgr/kg/day low molecular weight heparin (enoxyparine).

[The evaluation of the suitability of our cases for referral to a level I trauma center]

This study was performed on 200 patients with a prospective method, between July and October 1998. The aim of the study was to analyze the patients who were admitted directly or referred from another hospital, if they were suitable with the transfer criteria to a level I trauma center. One hundred and seven patients (53.5%) were admitted without ambulance and 93 patients (46.5%) by ambulance to our center. 34% of those patients applied directly and 66% of them were sent from other hospitals. Private ambulances consisted 70%, and 30% the belonged to the national health service. Only 26% of the ambulances had doctor as staff. The most common trauma etiologies were: traffic accidents (42.5%), falling from a height (37.5%) and assaults (11.5%). The mean Glasgow coma score (GCS) of the patients was calculated as 13.9 and mean revised trauma score was 11.7. The Glasgow coma score, revised trauma score and appropriateness to the transfer criteria of the American College of Surgeons were statistically analyzed according to the Fischer Exact test. The results revealed that 96% of the patients with RTS, 86% of the patients with GCS and 60% of the patients with ACS were not appropriate to the transfer criteria to a level I trauma center. In conclusion; we believe that GCS will predict better results in the triage of trauma patients with head trauma in our country.

Use of a modified occlusal bite guard to treat self-induced traumatic macroglossia (two case reports)

OBJECTIVE

To describe the use of a bite guard to avoid continued tongue trauma and edema.

DESIGN

Two case reports.

INTERVENTIONS

Bite raiser.

CONCLUSION

Muscle relaxation and a bite guard were used in a 16 years old male and 22 years old female with traumatic macroglossia, which allowed for rapid resolution of edema and prevented additional trauma to the tongue.

[Trauma and resuscitation course (TRC): evaluation of the first 2 years]

Eight Trauma and resuscitation Courses (TRC): two instructor and 6 student courses have been organized in Turkey between December 1998 and November 2000. Questionnaire results of 121 students and 63 instructors were reviewed. We strongly believe that these results will be supportive for the courses in the future. Fifty-five of the instructors were from university, and 8 were from teaching hospitals. 121 doctors attended six student courses, the average age of whom was 34. Average time period following university graduation was 10 years (3 months 43 years) for the participants. Among these, 94% found the course content sufficient. The course book was determined as insufficient in terms of drawings and pictures by 15%. The main target population of the course was selected as emergency service doctors and practitioners. As a result we determined that the main criticisms were insufficient practical and video sessions and the lack of drawings in the course book our main goal is to accomplish the required changes, and make new courses more yielding and profitable, thus introduce standardization in terms of trauma care nationwide.

[Esophageal injuries]

Despite progress in the management of esophageal perforations by early diagnosis, antibiotics, monitoring, and respiratory and nutritional support, it still remains as a disasterous condition. The most common cause of esophageal perforation is iatrogenic disruption. The result in the management of esophageal perforation is influenced by several factors: localization and size of the rupture, length of delay in diagnosis, age, extent of mediastinal and pleural contamination, the presence of underlying esophageal diseases, and inflammation or tumor at the perforation localization. In this study, 7 cases of esophageal perforations in the last six years have been analysed retrospectively. In study group, there were 5 males and 2 females, and the mean age was 36 (12-75). The most common cause of perforation was gunshot injury (3 cases), and stab wound (1 case), foreign body (1 case), iatrogenic distruption (2 cases). Three patients died and four patients were discharged from hospital with recovery. Esophageal perforation is a life-threatening condition. Early diagnosis and repair reduces the morbidity and mortality.

[Applications of the inferior vena cava filter for the prevention of the risk for pulmonary emboli]

The most serious and fatal complication of deep venous thrombosis (DVT) is still accepted as pulmonary embolism (PE). One of the methods used for PE prophylaxis is inferior vena cava filter(VCF). Between 1999 and 2000, VCF is used in 12 patients (8 male, 4 female) who were hospitalized in Trauma and Surgical Emergency Service of Istanbul Medical Faculty. 10 of the VCF used were permanent and 2 of them were temporary filters. 8 permanent filter were applied to patients with life-long paraplegia or quadriplegia due to spinal cord injury. Two patients to whom permanent filters were applied had malignancy. Patient who had the diagnosis of late stage cervical carcinoma, had DVT. In this patient, because of the high bleeding risk, we applied permanent filter. In the other patient, who had the diagnosis bladder carcinoma, had DVT despite the usage of low molecular weight heparin. In two patients who needed short term PE prophylaxis, had temporary VCF. In one of these patients, primary diagnosis was subarachnoidal hemorrhage due to head trauma. In the 8th day of hospitalization, DVT occurred. Because of high risk of intracranial bleeding, VCF was performed. The second patient had the diagnosis of subdural hematoma and subarachnoidal hemorrhage due to head trauma and multiple lower extremity fractures. VCF were applied in Istanbul Medical Faculty, Department of Radiology. For cannulation line of permanent VCF (LGM Venatech-B. Braun) right femoral vein was used. For temporary filters (Proliser Cordis-Johnson and Johnson Company), right internal jugular vein was the preferred way. Two multitrauma patients who had permanent filters died due to sepsis and multiorgan failure. In the follow up of other patients during the average period of 7.6 months, any problem due VCF application or by related complication and PE did not occur. Although larger patient groups with follow up period are necessary to evaluate better, we think that in PE prophylaxis, VCF is safe and effective modality.

US versus conventional radiography in the diagnosis of sternal fractures

PURPOSE

To investigate the value of ultrasonography (US) in the diagnosis of sternal fractures.

MATERIAL AND METHODS

Twenty-three patients (mean age 35.4 years) with a clinical suspicion of sternal fracture after blunt chest trauma were retrospectively reviewed. At admission, a.p. and lateral chest radiographies and sternal US were obtained. Sternal fractures were classified as nondisplaced or displaced. US and conventional radiographic findings were compared.

RESULTS

In 3/23 (13.0%) of the patients, no fracture was found by radiography or by US. Both radiography and US demonstrated sternal fractures in 16/23 (69.6%) of the patients. Sternal fractures were detected only by US while the conventional radiography was negative in 2/23 (8.7%) cases. Also in 2/23 (8.7%) of the patients with US positive for fracture, radiographies were suspicious. In 2 patients, the degree of fracture displacement on US was lesser than that found by radiography.

CONCLUSION

US was better than lateral radiography to diagnose sternal fractures; however, conventional radiography remains the standard means of demonstrating grade of displacement.

Hypertonic saline prevents early bacterial translocation in hemorrhagic shock

The most appropriate solution for volume replacement in hemorrhagic shock is controversial; however, hypertonic saline (HTS) solutions have recently gained widespread acceptance. In this study, various solutions were used to resuscitate rats in hemorrhagic shock, and their impact on the extent of bacterial translocation was investigated. Rats were bled to a mean arterial blood pressure of about 35 mmHg which was maintained for 30 min. They were then randomized into six groups. Blood pressure was found to be regulated by blood + lactated Ringer's solution (LR) and HTS + LR, but no significant improvement was observed in the control and LR groups. Groups II (7.5% HTS + 60 ml/kg LR) and IV (60 ml/kg LR + autologous blood) had a significantly better result than groups I (7.5% HTS), III (60 ml/kg LR), and IV (P < 0.05), among which no statistically different results were seen (P > 0.05). While no organisms were isolated from the mesenteric lymph nodes in the sham group, the rates of positive culture were 12.5%, 12.5%, 50%, 62.5%, and 62.5% in groups I, II, III, and the control group, respectively. Escherichia coli was the most commonly isolated organism. HTS + LR was demonstrated to be effective for decreasing the rate of early bacterial translocation to mesenteric lymph nodes and also for restoring the mean arterial pressure.

The use of laparoscopy as a primary diagnostic and therapeutic method in penetrating wounds of lower thoracal region

Diagnostic laparoscopy (DL) was found to be a sensitive and specific method that reduced the incidence of negative or nontherapeutic laparotomy in patients having penetrating abdominal trauma. Twenty-two patients with penetrating trauma of the lower thoracal region were evaluated by DL at the Emergency Department of the Istanbul Medical Faculty to decide on either laparotomy or conservative treatment. There were 7 (31.8%) female and 15 (68.2%) male patients. Mean age was 26.5 (2146) years. Three (13.6%) patients had gunshot wounds and 19 (86.4%) stab injuries. No peritoneal penetration was detected by DL in 11 (50%) patients, and none of these patients later required laparotomy. Of the remaining 11 patients who had peritoneal penetration, diaphragmatic laceration was detected in 9 (81.8%). Nineteen patients (86.4%) avoided nontherapeutic laparotomy. The specificity and sensitivity of DL were 100% in lower thoracal penetrating trauma. The positive diagnostic value and negative predictive value for peritoneal penetration were found to be 100%. The positive predictive value for therapeutic laparotomy and negative predictive value for nontherapeutic laparotomy were 100% as well. All patients who underwent only DL was discharged within 24 hours. There were no mortality or morbidity. Mean follow-up period was 13 months, and no associated complication was encountered during this time.

Comparison of preoperative imaging techniques (thallium technetium scan and ultrasonography) and intraoperative staining (with methylene blue) in localizing the parathyroid glands

We carried out a prospective study to compare the predictive value of preoperative thallium technetium scan, ultrasound (US) and intraoperative staining of the parathyroid glands (with methylene blue) in patients with parathyroid adenoma, parathyroid hyperplasia, thyroid carcinoma and thyrotoxicosis, in the Istanbul School of Medicine, Department of General Surgery. Methylene blue was given at a dose of 5 mg/kg/body weight in a 500 ml 5% Dextrose +0.9% saline solution 1 hour before surgery. All adenomas (10 patients), hyperplastic parathyroid glands (12 patients) and 45 of 52 suppressed glands (82%) were stained. In patients with thyroid carcinoma (7) and thyrotoxicosis (5), 42 of 48 normal parathyroid glands (87%) were stained. There were no maneuver-related complications. Thallium technetium scan (TT) accurately identified 10 of 10 (100%) parathyroid adenomas and 13 of 26 (50%) hyperplastic parathyroid glands. US successfully localized 10 of 10 (100%) adenomas and 18 of 26 (66%) hyperplastic glands. Neither technique was successful in identifying normal glands. The intraoperative identification of the parathyroid glands with methylene blue was found to be an effective, safe and cost-effective technique which helps the surgeon in the dissection and shows abnormal parathyroid glands more accurately than preoperative imaging techniques.