Patients with chronic conditions and their complex care needs in a tertiary care hospital.

INTRODUCTION: Health care for children with complex chronic conditions (CCC) constitutes an evolving and a challenging part of practices in pediatrics. These children need end-of-life services such as palliative care. The aim of this study was to identify the frequency of patients with CCC among all hospitalized children at our general pediatrics services and to describe the demographics, diagnosis, clinical spectrum, long-term care needs, and mortality data of patients with CCC. PATIENTS AND METHODS: All hospitalizations in 2018 at the general pediatric services were screened retrospectively. Patients' hospitalization diagnoses, gender, age, comorbid conditions, number of emergency admissions in 2018, intensive care unit needs, mortality rates, and the number of hospitalizations in 2018 were investigated. RESULTS: A total of 1591 patients were hospitalized for 2083 times in 2018. Overall, 145 of 1591 patients (9%) had CCC. Patients with CCC were hospitalized for 472 times (23% of all hospitalizations). The number of emergency admissions, the number of hospitalizations in 2018 and the need for intensive care, and the mortality rate during hospitalization for patients with CCC were significantly higher than those for patients without CCC. The median length of hospitalization in patients with CCC was significantly longer. CONCLUSION: Patients with CCC were hospitalized frequently and longer, had increased emergency and PICU admissions, and special long-term care needs. Pediatricians who pioneer care for children with CCC need education, training, and coordinated support to ensure qualified long-term care for these patients.

Fournier's gangrene: series of twenty patients.

BACKGROUND AND PURPOSE: Fournier's gangrene (FG) is a rare, rapidly progressive, fulminant form of necrotizing fasciitis of the genital, perianal and perineal regions. Our aim is to investigate the clinical signs, symptoms and factors which affect the clinical results of patients with FG in our clinic. PATIENTS AND METHODS: 20 patients having FG were admitted to our department during the past 6-year period. Age, gender, diabetes mellitus (DM), duration of symptoms, FG severity index score (FGSIS), colostomy, hospitalization time and number of debridements were investigated for their effects. RESULTS: 13 of our patients were male, 7 of them were female. The mean age was 52.2 years (range: 30-80 years). 85% of our patients had DM as a predisposing factor. The mean hospitalization time was 19.7 days (range: 6-45 days), and overall mortality was 20% (4 patients). Age and FGSIS have been found to be statistically significant factors among the parameters studied. DISCUSSION: FG is still an important disease with high mortality rates in spite of the developments in intensive care units and new-generation antibiotics. In conclusion, we have found that the age and FGSIS of the patient are the most important effecting factors.

Penetrating colon injury: experience of a single centre.

OBJECTIVE: Penetrating colonic injuries are amongst the most discussed intra-abdominal injuries because of the complexity of their management and the severe complications. Penetrating colonic injuries can be managed by either primary repair or diversion. There is a debate over which procedure has to be used under which circumstances. In this retrospective study we analyzed our experience to contribute to the answer. PATIENTS AND METHODS: The records of patients with penetrating colonic injury between January 1995 and December 2006 at the General Surgery Department of Atatürk University School of Medicine, were reviewed retrospectively. RESULTS: One hundred and forty-one patients were included in the study. Ten patients did not need any surgical treatment. Seventy-nine patients (56%) were treated without formation of a stoma and fifty-two patients (36.8%) with formation of a stoma. The overall complication rate was 50.3% (71 patients). The rate of septic complications was 33.3%. CONCLUSION: There is an ongoing debate whether formation of a stoma is indicated in penetrating colonic injury or not. Our clinical experience showed that severe faecal contamination, shock at presentation, and high CIS grades are associated with increased postoperative complications and mortality. Therefore the treatment of penetrating colonic injury in the presence of these risk factors should be stoma formation rather than primary repair.

Late complications of incisional hernias following prosthetic mesh repair.

BACKGROUND: Incisional hernias still continue to be a serious problem for surgeons. In this study, we aimed to investigate the effects of polypropylene mesh and mersilene mesh, which are frequently employed in incisional hernias, as well as the effects of their application techniques on late complications. METHODS: Two-hundred-sixty-four open abdominal hernia repairs were performed between 1986--2000, using prosthetic materials: polypropylene mesh and mersilene mesh were used in hernia repair. Mesh was placed as onlay, underlay and sandwich techniques. Follow-up data were obtained from medical records. RESULTS: Comparisons were made with respect to surgical techniques and to late complications such as recurrence, enterocutaneous fistula, intestinal obstruction, and infections. Enterocutaneous fistulas developed in two patients. Recurrence occurred in 6.4 per cent. Chronic infection and wound sinus formation occurred in 5 per cent. The causes of recurrence included smoking, cellulitis, chronic infection/sinus tract, upper abdominal localization, and obstruction. Fistula formation occurred in patients with no peritoneal prevention, which was statistically significant (p=0.012). Chronic infection/sinus tract was high in patients for whom mersilene mesh was used, and enterocutaneous fistula occurred in 2 patients. CONCLUSION: To prevent late complications, it is necessary to avoid the contact of mesh with bowel.

Dehydroepiandrosterone prevents oxidative injury in obstructive jaundice in rats.

We investigated the effect of dehydroepiandrosterone (DHEA) on oxidative injury in obstructive jaundice using three groups of rats: sham-operated group; common bile duct (CBD) group--the CBD was ligated; and DHEA group--DHEA administration followed CBD ligation. Liver function tests were performed using blood samples, and malondialdehyde concentration (MDA), superoxide dismutase activities (SOD), glutathione peroxidase (GPx), and total glutathione (tGSH) concentrations were measured in liver tissue. Serum alkaline phosphatase, gamma-glutamyltransferase and alanine aminotransferase activity were significantly elevated in the CBD group compared with the other groups. Serum aspartate aminotransferase and total bilirubin were highest in the CBD group; the MDA concentration was higher in the CBD group than the sham group. There were no significant differences in GPx activity among the groups. SOD activity and tGSH concentration were significantly lower in the CBD group than the other groups. DHEA may protect hepatic tissue against oxidative injury in obstructive jaundice by decreasing MDA concentration and increasing SOD activity and tGSH concentration.

Effects of short-term high carbohydrate or fat intakes on leptin, growth hormone and luteinizing hormone secretions in prepubertal fat-tailed Tuj lambs.

The aim of the current study was to evaluate the effects of high carbohydrate or fat diets, fed for 15 days at the end of breeding season, on leptin, GH and LH secretions in prepubertal fat-tailed Tuj lambs. For that purpose, 9-month-old ram-lambs were divided into three groups as control group (fed with basal ration, n = 4), high carbohydrate (HC) group, basal ration plus barley, n = 4), or high fat (HF) group (basal ration plus by-pass fat, n = 4). For the measurement of leptin and GH, blood plasma samples were collected on days 1, 4, 9 and 14 of the experiment. For the measurement of LH pulse frequency, serial blood samples were collected every 15 min for 6 h on day 14. Lambs were weighed and body condition scored (BCS) on days 1 and 15. Body weight and BCS increased towards the end of the study (p < 0.05). The BCS was higher in high energy groups at the end of the experiment (p < 0.05). Diet affected plasma leptin concentrations (p = 0.002) but time did not. The GH concentrations were not affected by diet or time. The LH pulse frequency appeared to be higher in HC and HF groups but there were no statistical difference between the groups. There was a significant positive relationship between overall BCS and corresponding leptin concentrations (R2 = 0.263; p = 0.010) and between LH pulse frequency and leptin concentrations (R2 = 0.594; p = 0.003). In conclusion, the present study suggests that rather than type of energy, amount of energy intake and body energy reserves are much important regulators of plasma leptin concentrations and LH pulse frequency in fat-tailed Tuj lambs.

Intrabiliary rupture in liver hydatid cysts: results of 20 years' experience.

To assess the diagnostic tools and results of treatment of biliary rupture observed in liver cyst hydatids, clinical findings of 562 patients with hepatic hydatid disease were reviewed. Imaging techniques were not very effective to determine intrabiliary ruptures. Rates of rupture sizes determined in the patients were as follows; 22 (%24.7) large, 38 (%42.7) small, and 29 (%32.6) occult. Most frequently utilized procedures for patients with intrabiliary rupture were Roux-en-y cystojejunostomy, tube drainage + omentoplasty, sutured fistula + omentoplasty, and sutured fistula + tube drainage. Of the total 25 external biliary fistulas, 21 closed spontaneously. Of the four fistulas that did not close, one was managed by internal drainage and three by endoscopic sphincterotomy. Preoperative diagnosis of biliary rupture in liver hydatid cyst allows early planning of operation and helps the surgeon design the operative strategy. In the treatment of cases with large rupture, internal drainage may be proposed.

Hydatid disease of the liver in children: evaluation of surgical treatment.

The medical records of 55 paediatric patients with hepatic hydatidosis, who were treated between 1990 and 2001 at Atatürk University, Turkey, were reviewed retrospectively. The most common symptoms at presentation were abdominal mass (32.7% of cases) and pain (81.8% of cases) in the right upper quadrant of the abdomen. Cysts were found in the right lobe in 41 patients, in the left lobe in four patients and in both lobes in 10 patients. Multiple hepatic cysts were present in 12 cases and eight patients also had cysts in other organs. Surgical procedures were evacuation of the cyst and management of the cavity with tube drainage, capitonnage, omentoplasty, cystectomy or segmentectomy. Long-lasting biliary fistula (two patients) and cholangitis (two patients) developed following evacuation and tube drainage, and one patient developed cholangitis after capitonnage. This review suggests that omentoplasty and capitonnage are more effective than tube drainage in the management of the cyst cavity.

[Thromboembolic prophylaxis after major abdominal surgery]. / Büyük karin ameliyatlarindan sonra tromboembolik profilaksi.

PURPOSE: To investigate the efficacy of prophylaxis modalities after major abdominal surgery. PATIENTS AND METHODS: Patients who underwent major abdominal surgery between October 1998 and October 1999 were randomly divided into 3 groups. The patients in Group 1 received compression stockings, in Group 2 0.3 ml low-molecular weight heparin (nadroparine calcium 0.3 ml, 2850 IU AXa LMWH) subcutaneously and in Group 3 compression stockings and 0.3 ml LMWH. All symptomless patients evaluated with low extremity deep venous Doppler ultrasonography (DUSG), and patients who had pulmonary embolus (PE) suspicion evaluated with pulmonary scintigraphy. RESULTS: There were 91 patients in Group 1, 91 patients in Group 2 and 92 patients in Group 3. The mean age was 57.25 +/- 13.12, 54.53 +/- 13.54, and 53.65 +/- 13.28 respectively. Male/female ratio was 51/38, 56/35 and 62/30, in Group 1, 2 and 3 respectively. Twenty-seven patients in Group 1, 26 patients in Group 2 and 37 patients in Group 3 had risk factors. DUSG showed deep venous thrombosis (DVT) on the 7th postoperative day in 10 patients in Group 1, in 8 patients in Group 2 and in 3 patients in Group 3. Pulmonary scintigraphy showed PE suspicion in 6 patients in Group 1, 1 patient in Group 2 and 1 patients in Group 3. Wound hematoma and hemorrhage from abdominal drains were developed in 1/0, 8/2 and 3/1 patients in Groups 1, 2 and 3 respectively. Four patients in Group 1 and 2 patients in Group 2 died during the treatment (2.2%). Satistical analysis showed significant differences in PE and wound hematoma between Groups 1 and 2, in DVT and PE between Groups 1 and 3, in risk factors between Groups 2 and 3 (p < 0.05). The differences in DVT and PE and hematoma between group 2 and 3 were not significant. CONCLUSION: All treatment modalities could not prevent all thromboembolic complications. In our study combined treatment was the most effective one.

[Hepatic injuries. Surgical treatment experience]. / Karaciger yaralanmalarinda cerrahi tedavi deneyimimiz.

PURPOSE: To evaluate the results of the surgical treatment of hepatic injuries in our institution for liver injuries. PATIENTS AND METHODS: One hundred seventy four patients who underwent operations between January 1986-December 1999 in Atatürk University Medical School, Emergency Service were reviewed retrospectively. RESULTS: 135 patients were male (77.5%). The mean age was 25.4 (range 3-84). Sixty three patients (36.3%) had only hepatic injuries and the others had co-existing abdominal organ injury [62 patients (35.7%) had one organ, 29 (16.7%) had two, 17 (9.7%) had three, 2 (1.1%) had four, and 1 (0.5%) had 5 organ injuries]. Five patients (2.8%) had inferior vena cava and 1 (0.5%) had vena porta injuries. One hundred seven patients (61.4%) had blunt, 44 (25.3%) had stab wound and 23 (13.3%) had gunshot injuries. Management was simple suture in 104 patient (60%), primary suture + surgical cell patching in 52 (29.8%), hepatectomy (5 right hepatectomy, 5 non anatomic hepatectomy) in 10 (5.7%), perihepatic packing in 4 (2.3%), primary suture + omental patch in 2 (1.1%), primary suture + arterial ligation in 2 (1.1%). Eleven patients (16.4%) in penetrating trauma group "Penetrating Abdominal Trauma Index" (PATI) score were higher than 25. Fever was the most common complaint postoperatively (5%). Three patients (1.7%) underwent reoperation. Twenty-six patients (14.9%) which one of them ware died. Died in the postoperative periods, 23 (13.2%) had blunt and 3 (1.7%) had penetrating traumas. CONCLUSION: Liver trauma still has high mortality rate injuries are very momentous. Especially blunt trauma related hepatic.

Multifocal carcinoid tumor resembling a solitary tumor: report of a case.

A laparotomy was performed on a 44-year-old male patient with an acute abdomen who had findings suggestive of acute appendicitis and a periappendicular abscess. A histopathological examination revealed a carcinoid tumor infiltrating the intestinal serosa. The distal ileum and cecum were infiltrated with more than 40 multifocal tumors, with the largest measuring 1 cm in size. The distal ileum and cecum were resected. We failed to find any distant metastases either peroperatively or during postoperative scintigraphic tests. In addition, the patient had no symptoms of carcinoid syndrome either before or after surgery. No recurrence was experienced. We thus conclude that primary multifocal carcinoid tumors may act as a solitary carcinoid tumor, and the largest tumor tends to indicate the overall clinical outcome.

Plasma concentrations of 13,14-dihydro-15-keto PGF2alpha and progesterone during the oviposition cycle of the domestic goose (Anser anser domesticus).

Plasma 13,14-dihydro-15-keto prostaglandin F2alpha (PGFM) and progesterone levels were determined in actively ovulating, 1- to 2-yr-old female geese (Anser anser domesticus) at hourly intervals during the oviposition cycle, using the enzyme immunoassay (EIA) technique. The plasma PGFM concentration showed a peak at the time of oviposition and decreased to a basal level after oviposition. Progesterone levels began to surge approximately 12 to 13 h before ovulation and reached a peak 2 to 3 h before ovulation. The plasma progesterone concentrations returned to basal level at the time of ovulation. The present method of EIA was found to have practical application in analyses of progesterone and PGFM in plasma of birds.

Intra-abdominal extrahepatic echinococcosis.

Twenty-seven patients who were treated surgically because of extrahepatic abdominal hydatid disease between 1981 and 1999 were retrospectively reviewed. Nineteen patients had coexistent hepatic cysts while 8 patients had only peritoneal cysts. The cysts were located in the spleen, pancreas, adrenal gland, mesentery of the intestines, ovaries, retroperitoneum, omentum, abdominal wall, rectovesical region, and the psoas muscle. Due to organ destruction because of large cysts in 8 patients, the involved organ had to be sacrificed. The other 19 patients were treated by a pericystectomy. No postoperative mortality or severe morbidity was seen. In conclusion, symptomatic or large cysts should be surgically treated. In cases suspected of having peritoneal spillage, antihelminthic drugs should be administered. In addition, small asymptomatic cysts may also be effectively treated with antihelminthics.

[Perforated peptic ulcers]. / Peptik ülser perforasyonlari.

Two hundred forty-eight patients were operated for perforated peptic ulcer between 1983 and 1998. Of the patients 112 (45.1%) had chronic, 34 (13.7%) had acute ulcer history and 102 (41.2%) had no ulcer history. Of the patients 228 (92.0%) had duodenal, 9 (3.6%) had juxtapyloric, 6 (2.4%) had marginal, and 5 (2.0%) had antral ulcer. Forty two patients (16.9%) admitted within 12 hours and 206 patients (83.1%) between 12 hours and six days after perforation. Simple closure and omental patch was performed in 32 patients (12.9%) who had severe concomitant illness and 126 (50.8%) intraabdominal sepsis, truncal vagotomy + pyloroplasty in 32 (12.9%), simple closure + omental patch + truncal vagotomy + gastroenterostomy in 34 (13.7%), simple closure + omental patch + parietal cell vagotomy in 21 (8.5%), truncal vagotomy + antrectomy in 3 (1.2%). Patients who didn't have definitive procedure received H2 receptor blockers or proton pomp inhibitors. One hundred ninety-three patients (77.8%) underwent endoscopic control. Two of 53 patients with definitive procedure (3.8%) and 34 of 140 patients (24.3%) with simple closure had recurrence. Two patients in simple closure group underwent parietal cell vagotomy, the others received medical treatment. The recurrence rate was significantly higher in simple closure group (p < 0.01).

Surgical treatment of hydatid disease of the liver: review of 304 cases.

HYPOTHESIS: To review the results of different modalities of treatment of hydatid disease of the liver. DESIGN: Retrospective study of 304 patients. SETTING: A university hospital in Turkey. PATIENTS: Three hundred four patients with hepatic hydatid disease who underwent operation between 1981 and 1996. MAIN OUTCOME MEASURES: Mortality and morbidity. RESULTS: Two hundred thirty-eight patients had a cyst on the right lobe, 41 patients had a cyst on the left lobe, and 25 patients had a cyst on both lobes. Forty-five patients had multiple hepatic cysts and 18 patients had coexisting cysts in other intra-abdominal organs. Surgical procedures were tube drainage, capitonnage, omentoplasty, cystectomy, segmentectomy, and cystoenterostomy. Of the patients with tube drainage, 36 developed an infection of the remaining cavity, 10 developed long-lasting biliary fistula, 8 developed cholangitis, and 6 developed septicemia. Four patients died of unreleated complications. Of the patients with capitonnage, 7 developed cholangitis and 3 developed an infection of the remaining cavity. Of the patients with omentoplasty, 1 developed an infection of the remaining cavity and 1 developed cholangitis. One patient who underwent segmentectomy developed pulmonary complications. Of the patients with cystoenterostomy, 1 developed cholangitis, 1 developed septicemia, and 1 developed pulmonary complications. CONCLUSION: For management of hydatid disease of the liver, capitonnage, omentoplasty, cyst excision, segmentectomy, or cystoenterostomy are all superior to tube drainage.

Posttraumatic gallbladder torsion in a child.

Torsion of the gallbladder in an 8-year-old boy, which was precipitated by blunt abdominal trauma from a ball-strike during a soccer game, is reported. Of the 13 reported childhood cases of gallbladder torsion, this is the first to be precipitated by blunt abdominal trauma in the presence of congenital anatomic predilection.