Assessment of patients who presented to the emergency department with mushroom poisoning.

OBJECTIVE: This study aimed to assess the demographic characteristics, emergency department (ED) complaints, laboratory findings, and latent phase periods of patients who presented to the ED due to mushroom poisoning (MP) as well as the efficacy of conventional and hemofiltration therapies. METHOD: The study was conducted on patients who presented to the ED with MP between 2010 and 2012. The patient's demographic characteristics, complaints at the ED, latent phases, laboratory findings, and treatments of MP cases were evaluated. RESULTS: The mean age of patients was 38.03 ± 15.96, where 63.8% of them were female and 36.2% were male. Visits occurred most frequently in the autumn (32.6%). When presenting to the ED, the most frequent complaint was nausea-vomiting. The aspartate aminotransferase (AST), alanine aminotransferase (ALT), international normalised ratio (INR), and blood urea nitrogen values of patients with a latent phase between 0 h and 5 h were significantly lower than the values of patients with a latent phase between 6 h and 24 h. In this study, 62% of the patients (n = 36) had stomach lavage and received activated charcoal. Altogether, 55.2% of the patients had received conventional therapy, 37.9% of them received hemofiltration, and all of them received supportive treatment. The AST, ALT, and INR values of those who had received hemofiltration and conventional therapies were significantly higher than of those who received only supportive treatment (p < 0.01). CONCLUSION: Hemofiltration, in combination with conventional therapy, seems to be an effective treatment for reducing mortality in suspected MP cases involving late acting toxins.

Cardioprotective effect of aminoguanidine in combination with steroid therapy after blunt chest trauma.

BACKGROUND: Cardiac contusion is an important cause of mortality after blunt chest trauma (BCT). The aim of this study was to investigate the therapeutic efficacy of the usage of aminoguanidine (AG), in myocardial damage occurring after BCT, alone and in combination with methylprednisolone (MP). METHODS: Thirty-five female Wistar albino rats were randomly assigned to five groups (n = 7) including: sham controls (S); only cardiac contusion (CONT); cardiac contusion treated with methylprednisolone (CONT+MP); cardiac contusion treated with aminoguanidine (CONT+AG); and cardiac contusion treated with methylprednisolone and aminoguanidine (CONT+MP+AG). Seven days following the treatments, heart and serum specimens were evaluated histopathologically, immunohistochemically, and biochemically in all groups. RESULTS: Serum AOPP and Tn-I levels increased significantly after cardiac contusions. Haemorrhage, tissue degeneration, and necrosis development was evident following contusions. Increased iNOS expression in myocardial tissue was significantly decreased in the CONT+AG+MP group compared to CONT+AG and CONT+MP groups (p = 0.001 and p = 0.011, respectively). The combined treatment of AG and MP increased Bcl-2 expression significantly after contusions compared to the other treatment groups. CONCLUSIONS: Combined usage of AG, a selective iNOS inhibitor, with MP, in cardiac contusions, showed a more powerful cardioprotective effect by increasing Bcl-2 expression and reducing iNOS expression (Tab. 3, Fig. 4, Ref. 33).

Comparison of hyperpronation and supination-flexion techniques in children presented to emergency department with painful pronation.

CONTEXT: Radial head subluxation, also known as 'pulled elbow', 'dislocated elbow' or 'nursemaid's elbow', is one of the most common upper extremity injuries in young children and a common reason to visit Emergency Department (ED). AIM: To compare supination of the wrist followed by flexion of the elbow (the traditional reduction technique) to hyperpronation of the wrist in the reduction of radial head subluxations (nursemaid's elbow) maneuvers in children presented to ED with painful pronation and to determine which method is less painful by children. SETTINGS AND DESIGN: This prospective randomize study involved a consecutive sampling of children between 1-5 year old who were presented to the ED with painful pronation. MATERIALS AND METHODS: The initial procedure was repeated if baseline functioning did not return 20 minutes after the initial reduction attempt. Failure of that technique 30 minutes after the initial reduction attempt resulted in a cross-over to the alternate method of reduction. STATISTICAL ANALYSIS USED: Datas were analyzed using SPSS for Windows 16.0. Mean, standard deviation, independent samples t test, Chi-square test, and paired t test were used in the assessment of pain scores before and after reduction. RESULTS: When pain scores before and after reduction were compared between groups to determine which technique is less painful by children, no significant difference was found between groups. CONCLUSIONS: It was found that in the reduction of radial head subluxations, the hyperpronation technique is more effective in children who were presented to ED with painful pronation compared with supination-flexion. However, there was no significant difference between these techniques in terms of pain.

The role of S100B protein, neuron-specific enolase, and glial fibrillary acidic protein in the evaluation of hypoxic brain injury in acute carbon monoxide poisoning.

The main purpose of this study was to assess the role of S100B protein, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP) in the evaluation of hypoxic brain injury in acute carbon monoxide (CO)-poisoned patients. This cross-sectional study was conducted among the patients with acute CO poisoning who referred to the emergency department in a 1-year period. Serum levels of S100B protein, NSE, and GFAP were determined on admission. A total of 55 CO-poisoned patients (mean age ± standard deviation, 45 ± 20.3 years; 60% women) were included in the study. The control group consisted of 25 healthy adults. The patients were divided into two groups according to whether they were conscious or unconscious. The serum levels of S100B, NSE, and GFAP were higher in patients than that in the control group. There was no significant difference between unconscious and conscious patients with respect to these markers. There was a statistically significant difference between the conscious and unconscious patients and the control group in terms of S100B and NSE levels. There was also a statistically significant difference between the unconscious patients and the control group in terms of GFAP levels. Increased serum S100B, NSE, and GFAP levels are associated with acute CO poisoning. These biomarkers can be useful in assessing the clinical status of patients with CO poisoning.

Cryopreservation of Fraser photinia (Photinia x fraseri Dress.) via vitrification-based one-step freezing techniques.

An efficient vitrification-based cryopreservation procedure was developed for Fraser photinia shoot apices by assessing the influences of various vitrification solutions (PVS1, PVS2, PVS3 and VSL) and different vitrification methods (cryovial vitrification, droplet vitrification and droplet freezing) on shoot regrowth. Moreover, influences of cold-hardening period (0 to 8 weeks), preculture medium (with sucrose and proline) and regrowth medium (QL plus 4.4, 8.8 and 17.6 micromolar BA) were also evaluated. Among the different procedures tested, best shoot regrowth (40.3 percent) was achieved by using a droplet vitrification technique in which cold-hardened and precultured shoot apices were vitrified for 120 min at 0 degree C in droplets, rapidly cooled, thawed and then cultured on 17.6 micromolar BA-containing QL medium. Overall results indicated the importance of not only the composition of vitrification solution, and preculture and regrowth media, but also the application of an appropriate vitrification technique to achieve optimum recovery post-cryopreservation.

Current status and conservation of Pistacia germplasm.

The genetic erosion of Pistacia germplasm has been highlighted in many reports. In order to emphasize this and to focus more attention on this subject, national and international (especially IPGRI and IFAR) institutions have initiated projects proposing to characterize, collect and conserve Pistacia germplasm. Therefore, this paper reviews recent research concerning conventional (in situ and ex situ) and unconventional biotechnological conservation strategies applied to the preservation of Pistacia germplasm. As regards conventional conservation, the majority of germplasm collections of Pistacia species are preserved on farms (in situ) and in seed and field genebanks (ex situ), as well as in the wild, where they are vulnerable to unexpected weather conditions and/or diseases. Hence, complementary successful unconventional in vitro methods (organogenesis, somatic embryogenesis and micrografting) and slow-growth storage conditions for medium-term preservation of Pistacia are presented together with the morphological and molecular studies carried out for the characterization of its species in this review. Moreover, special attention is additionally focused on cryopreservation (dehydration- and vitrification-based one-step freezing techniques) for the long-term preservation of Pistacia species. Possible basic principles concerning the establishment of a cryobank for the successful conservation of Pistacia germplasm are also discussed.

Image-guided microneurosurgical management of small arteriovenous malformation: role of neuronavigation and intraoperative Doppler sonography.

INTRODUCTION: The goal of this study was to evaluate the efficacy and reliability of neuronavigation and intraoperative microvascular Doppler sonography (MDS) for identifying afferent (feeding) and efferent (draining) vessels as well as for controlling the totality of the surgical resection of arteriovenous malformations (AVMs). METHODS: Between June 2000 and November 2005, twenty-five patients with small arteriovenous malformations (grades I-III) underwent microsurgical removal at our institution. A passive-marker-based neuronavigation system (Brain Lab, Munich, Germany), and an intraoperative MDS (Multi Dop X system, DWL, Germany) were used in this surgery. Blood flow velocities (BFV) in afferent and efferent vessels were recorded before and after removal of AVM. The preoperative neurological status and postoperative outcome were recorded. Patient follow-up monitoring ranged from 4 months to 3 years (mean: 16 months). RESULTS: The calculated registration accuracy of the neuronavigation computer ranged between 0.2-1.7 mm (mean: 1.1 mm). Before AVM removal the mean BFV of afferent vessels was 56.5+/-13.4 (28-98 cm/s) and the PI varied by 0.40+/-0.11 (0.25-0.66), after AVM removal these values reduced to 4.8+/-0.8 cm/s and 0.26+/-0.05, respectively. Similarly, before AVM removal, the mean BFV of efferent vessels was 13.5+/-4.5 (4-20 cm/s) and PI was 0.4+/-0.2 (0.34-0.56), after AVM removal both BFV and PI were not recorded. Complete removal of the AVMs was accomplished in 24 (96%) out of 25 patients which was confirmed with postoperative digital subtraction angiography (DSA). While there was no mortality, three patients (12%) had a worsening in their neurological status after surgery. CONCLUSION: Image-guided microneurosurgery with intraoperative MDS is a safe, effective, and reliable method for identifying the afferent and efferent vessels and for confirming the complete resection of AVMs. These benefits of image-guided microsurgery were most apparent for small, deep-seated AVMs that were not visible on the surface of the brain. In addition these techniques reduce the operative time and blood loss during AVM resection.

Intraoperative microvascular Doppler sonography in aneurysm surgery.

OBJECTIVE: The goal of this study was to evaluate the efficacy and reliability of intraoperative microvascular Doppler sonography (MDS) for the assessment of cerebral haemodynamics in aneurysm surgery. METHODS: For 40 patients (21 men, 19 women, mean age 54.0 years, range 23-73 years) who underwent surgery for the treatment of 48 intracranial aneurysms, microvascular Doppler sonography with a 20-MHz microprobe was used before and after clip application, to confirm the complete obliteration of the aneurysm. Postoperative angiography was performed to assess the complete occlusion of the aneurysm and the patency of adjacent vessels. The findings of MDS were analysed and compared with the postoperative angiography. RESULTS: A 1-mm diameter microprobe was able to insonate all vessels of the circle of Willis and their major branches and perforating arteries were reliably insonated. The aneurysm clip was repositioned on the basis of the MDS findings in 12 out of 48 patients (25%). For 9 aneurysms (18.7%) MDS exposed a relevant stenosis of an adjacent vessel induced by clip positioning that had escaped detection by visual inspection. Clip repositioning resulted in complete occlusion of the aneurysms in 7 of 9 cases (14.5%). In two cases, additional wrapping became necessary as it was not possible to achieve complete clipping. The mean duration of MDS investigations was 5.3 minutes. There were no complications of intraoperative MDS probe use. CONCLUSION: Intraoperative MDS should be used routinely in cerebral aneurysm surgery, especially for large, complicated and giant aneurysms. Intraoperative MDS is a feasible, safe, and very reliable technique in aneurysm surgery. This technique is a valuable tool, in many instances, in place of intraoperative angiography for the surgical treatment of aneurysms.

Surgical treatment of distal anterior cerebral artery aneurysms with horizontal head position.

OBJECTIVE: In the surgery for a distal anterior cerebral aneurysm which is applied with a vertical head position, the dome of the aneurysm makes it difficult the expose the neck and the proximal artery. This study was performed to evaluate the applicability of the alternative contralateral interhemispheric approach with a horizontal head position for clipping these aneurysms. METHOD: The head of the patient was placed in the horizontal position such that the aneurysm side remained at the top and then tilted 45 degrees superiorly. On the contralateral side, the craniotomy, interhemispheric dissection and clipping were performed in 12 patients with 13 aneurysms. RESULTS: All aneurysms were clipped successfully. Problems in the standard supine position such as the obstruction of the access to the aneurysm neck and the proximal artery by the dome were not encountered. Vasospasm developed in 4 patients and akinetic mutism in 1 patient; postoperative convulsion due to an inadvertent cortical venous injury in one patient resolved with medical treatment. Hydrocephalus developed in 2 patients; one patient needed placement of a ventriculoperitoneal shunt while the other responded to occasional lumbar punctures. Mortality or permanent morbidity did not occur. CONCLUSION: The horizontal head position may be an alternative for circumventing difficulties posed by the location of distal anterior cerebral artery aneurysms.

Neuronavigation in skull base tumors.

OBJECTIVE: Computer-assisted neuronavigation was used in 87 cases of skull base lesions (SBLs). Preoperative planning and intraoperative identification of anatomic landmarks is especially important in SBLs since it helps to avoid or minimize surgical morbidity and mortality. In this study, we assessed the accuracy and the clinical usefulness of a frameless system based on the optical digitizer in SBLs. PATIENTS AND METHODS: Between April 2000 and March 2003, eighty-seven patients with SBLs were operated on in our department using cranial neuronavigation. A passive-marker-based neuronavigation system was used for intraoperative image guidance. There were 56 women and 31 men. The patient's ages ranged from 4 to 76 years (average: 45.7 year). The locations of the tumors reported in this series were as follows: frontobasal, 24 cases; sellar/parasellar, 32 cases; petroclival, 16 cases; tentorial/subtemporal, 15 cases. RESULTS: The computer-calculated registration accuracy ranged between 0.3 and 1.7 mm (mean, 1.1 mm). Gross total removal of the SBLs was accomplished in 82 out of 87 patients as was confirmed on postoperative CT and MRI scans. The follow-up period ranged from 1 month to 48 months (average: 20.1 months). Overall mortality and severe morbidity (meningitis, permanent cranial nerve deficits, and cerebrospinal fluid fistulae) rates were 4.6 % and 33.3 %, respectively. CONCLUSION: The image-guided surgery is a valuable aid for safe, helpful and complete removal of SBLs of the brain where accurate localization of the lesion is critical. Although our preliminary series is not large, interactive image guidance provides a constant display of surgical instrument position during surgery and its relationship with the SBLs components, surrounding normal brain, and vascular structures, providing valuable guidance to the surgeon during an operation. Our experience with the neuronavigation suggests that image guidance is helpful in this type of lesions, providing better anatomic orientation during skull base surgery, delineating tumor margins and their relation to critical neurovascular structures.

Successful surgical excision of juvenile-type spinal arteriovenous malformation in two stages following partial embolization.

The case of a 24-year-old man with a juvenile-type spinal arteriovenous malformation is reported. Spinal angiography and magnetic resonance image revealed a juvenile (Type III) AVM at the cervical spine. This spinal malformation was successfully resected with a posterior and anterior surgical approach in two stages following partial embolization.

Anterior cervical foraminotomy for unilateral spondylotic radiculopathy.

Anterior cervical foraminotomy (ACF) was developed under the concept of functional spine surgery, which directly eliminates compressive pathological factors while preserving functional anatomic features. The authors reviewed their results to determine the efficacy of the approach for unilateral cervical spondylotic radiculopathy (CSR). Nineteen patients were treated with the ACF with a follow-up from 12 to 36 months. There were 10 men and 9 women (mean age 49.8). Fourteen patients had a single ACF, and 5 had procedures at adjacent levels. The procedure involves microsurgical removal of the lateral portion of the uncinate process to identify the nerve root. Seventeen patients (89.5 %) were symptom-free or clearly improved, one (5.3 %) was unchanged and one patient (5.3 %) was worse in the visual analogue scale (VAS) score for radicular pain. One patient had developed contralateral foraminal stenosis at the level of the surgery and had undergone anterior discectomy and fusion. ACF provided good or excellent outcomes, with minimal morbidities, for patients with CSR. The advantages of ACF include direct decompression of the nerve root, and the preservation of the intervertebral disc and the motion segment. Thus, fusion-related sequelae, including graft-related complications, graft site complications and the adjacent level disease are avoided. The ACF procedure appears to be a good alternative for carefully selected patients with unilateral CSR.

The surgical management of traumatic C6 - C7 spondyloptosis in a patient without neurological deficits.

An unusual case of traumatic C6 - 7 total spondyloptosis with neurologically intactness at the time of injury is reported in a 35-year-old man. The patient was treated with a single-stage combined anterior-posterior and anterior operation to restore the cervical spondyloptosis, and creation of a three-column stabilization of the spine without neurological deficits. To the best of the authors' knowledge, there is no case report of traumatic spondyloptosis of cervical spine, presenting without neurological deficits in the pre- and postoperative periods. A brief summary of the clinical presentation, the surgical technique, and a review of the relevant literature are presented.

Post-operative sequential chemo-radiotherapy in high-grade cerebral gliomas with fotemustine.

High-grade gliomas are the most common primary brain tumors in adults. Twenty-seven patients with histopathologically proven anaplastic astrocytoma and glioblastoma multiforme were enrolled in this study from November 1998 to August 2002. Radiotherapy was administered after surgery and fotemustine (100 mg/m2) was sequentially administered every 3 weeks for 6 cycles. Overall, 111 cycles were administered to the 27 patients (median, 5 cycles; range, 1 to 6 cycles). Myelosuppression was mild to moderate. The median overall survival and progression free survival were 11+/-3.1 months (95%CI, 4.9-17.1) and 8+/-0.5 months (95%CI 7.1-8.9), respectively. One-year and two-year survivals were calculated at 48% and 7%, respectively. Significant prognostic factors (P<0.05) via univariate analysis were divided into two groups: completion of 6 cycles of chemotherapy versus incompletion of 6 cycles of chemotherapy. This trial demonstrates that postoperative radiotherapy and sequential fotemustine therapy is feasible, well tolerated, and may prolong survival in patients with newly diagnosed high-grade gliomas.

Is skull fracture necessary for developing an intradiploic pseudomeningocele as a complication of head injury in adulthood?

We report the case of an adult with a posttraumatic intradiploic pseudomeningocele which caused an expanded osteolytic skull lesion. Local pain and swelling, the only symptoms of the lesion, regressed after surgery. Intradiploic pseudomeningocele must be distinguished from intradiploic leptomeningeal cyst, which is of traumatic origin or arachnoid cyst and epidermoid cyst, which are of congenital origin. We also discuss the development of intradiploic pseudomeningoceleafter head trauma without skull fracture in adulthood and suggest a possible mechanism.

Nocardia brain abscess mimicking brain tumour in immunocompetent patients: report of two cases and review of the literature.

Nocardia brain abscess is a rare intracranial lesion and has been reported in immunocompromised patients. An optimal treatment approach has not been established. However, early diagnosis and appropriate antimicrobial therapy are very important factors for a good outcome. We report two unusual cases of Nocardia brain abscess simulating brain tumour in immunocompetent patients. One of the cases was presumed to be a primary brain tumour and the other a metastatic brain tumour. They underwent surgical gross total resection. After Nocardia asteroides was seen on Gram's stain and subsequently identified by culture, appropriate antibiotic therapy was initiated.

Successful surgical excision of a gigantic cerebral hydatid cyst.

In this study, an extremely rare case of a gigantic cerebral hydatid cyst is presented. A right frontotemporal hydatid cyst was detected by computed tomography and magnetic resonance imaging. This lesion was extirpated successfully with intact contents with the aid of a neuronavigation system. The literature is reviewed and possible postoperative complications are discussed with the published reports.

Surgical treatment of thalamic hematomas via the contralateral transcallosal approach.

Acute management of deep-seated hematomas remains controversial. Since patients with these hematoma later tend to develop severe edema and necrosis around the lesion, when surgery is indicated it should be done as early as possible. The purpose of this study was to compare whether early surgical removal and conservative treatment of primary thalamic hematoma correlated with improved neurological outcome. Last year, 61 patients with primary thalamic hematomas were admitted to our institution. Of these, 21 underwent surgery via contralateral transcallosal approach during the ultraearly stage (within 6 hours) after the apoplectic attack, and 24 patients were treated conservatively. Another 16 patients were excluded from the study due to systemic disease, mild hematoma (<40 cc), and deep coma associated with absence of brain stem reflexes. Initial Glasgow coma scores (GCS) at admission were similar for operated and nonoperated patients (8.64 +/- 1.93 versus 9.50 +/- 2.10, P>0.05). In the operated group, two patients had good recoveries and returned to normal life (Glasgow Outcome Score, or GOS, I), four had moderate disability and needed partial care (GOS II), six had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). However, in the nonoperated group, one patient had good recovery and returned to normal life (GOS I), two had moderate disability and needed partial home care (GOS II), three had severe disability and needed nursing care (GOS III), and six had a vegetative state (GOS IV). In this group, the 30-day mortality rate was 50%. Mortality was markedly lower in the operated group (14.3%) than the nonoperated group. and this difference was statistically significant (chi2=3.33, P<0.05). From this study, we believe that evacuation of primary thalamic hematoma via the contralateral transcallosal microsurgical approach may be useful for deciding on the indication and predicting the functional prognosis.

The effect of allopurinol on focal cerebral ischaemia: an experimental study in rabbits.

In this experimental study, the neuroprotective effect of the xanthine oxidase inhibitor allopurinol on focal cerebral ischaemia created by permanent middle cerebral artery occlusion (MCAO) was investigated. Using high performance liquid chromatography (HPLC), we measured hypoxanthine, xanthine, and uric acid (UA) levels in rabbit brains following focal cerebral ischaemia. Rabbits were randomly and blindly assigned into four groups of eight animals each. The control groups received 2% carboxymethylcellulose solution, while 10% allopurinol 150 mg/kg was given to the treatment group 1 h before ischaemia. Each group was subdivided into two groups which were sacrificed 4 h or 24 h after ischaemia, respectively. UA and xanthine values of the rabbits in the control groups were quite high at both times and highest after 24 h, particularly in the centre of the ischaemia. A significant decrease in UA and xanthine values was observed in rabbits that were given allopurinol (P<0.05). According to our results, it was concluded that allopurinol pretreatment protects neural tissue in the early period after arterial occlusion and prevents cerebral injury in the late period, especially in the perifocal area, possibly by preventing the formation of free radicals with xanthine oxidase inhibition.

Posterolaterally displaced type IIA odontoid fractures.

A case of type IIA odontoid fracture with posterolateral dislocation accompanied by spinal cord injury is presented. Cervical traction was employed but reduction could not be achieved with up to 8 kg of traction. The patient was treated with intraoperative reduction and C1-2 posterior transarticular screw fixation with supplemental bone-wire fusion, and rigid fixation was obtained without any complication.