The effect of a chitosan coating on the adhesive potential and tensile strength of polypropylene meshes.

PURPOSE: The polypropylene mesh used for the repair of abdominal wall hernia can cause intraabdominal adhesions. In this study, the effect of chitosan coating of the polypropylene meshes on the adhesion and tensile strength of the meshes was investigated. METHOD: After coating polypropylene meshes with 2 % chitosan, 5 × 3 cm patches were prepared. Under general anesthesia, sterile laparotomy was performed in 96 Wistar albino female rats that were equally allocated to 6 groups. In the first group, only laparotomy was performed. In the second group, chitosan was applied to the peritoneal cavity, and the laparotomy was closed. In the third group, polypropylene (prolene) patches were used to close the abdomen; in the fourth group, polypropylene polyglecaprone 25 (ultrapro) mesh patches were used to close the abdomen. In the fifth and sixth groups, chitosan-coated versions of the meshes used in the third and fourth groups, respectively, were applied. All skin incisions were closed in all groups. On the 7th and 21st days, eight randomly selected rats from each group were killed. The abdomen was opened, and the adhesions were evaluated using the diamond score. The tensile strength of the meshes was measured by an Instron 4301 device. The histopathological evaluation of the inflammatory response was performed according to the Ehrlich and Hunt classification. RESULTS: The adhesion score was comparable among mesh groups but higher when mesh groups were compared with the control and chitosan groups (p<0.001). The tensile strength of meshes did not differ among mesh groups. Histopathologically, meshes with or without chitosan were similar in terms of inflammatory findings. CONCLUSIONS: The chitosan coating did not affect the adhesion potential, the tensile strength, or the inflammatory response of the polypropylene meshes.

Fournier's gangrene: an analysis of 80 patients and a novel scoring system.

BACKGROUND: To create a better scoring system for outcome prediction for patients with Fournier's gangrene in order to design more appropriate and feasible management strategies. METHODS: Using logistic regression, the medical records of 80 patients who underwent surgery for Fournier's gangrene in the last 10 years were reviewed using a prospectively maintained database, and a novel scoring system was adopted combining this data with the Fournier's gangrene severity index (FGSI). The new system consists of a physiological score, an age score, and an extent of gangrene score. RESULTS: The mortality rate of the 80 patients was 21%. Using the new scoring system (UFGSI), at a threshold value of 9, there was a 94% probability of death with a score greater than 9 and an 81% probability of survival with a score of 9 or less (P < 0.001). The receiver operating characteristics (ROC) analysis concluded that the new scoring system was more powerful than the FGSI (P = 0.002). CONCLUSIONS: The power of the novel scoring system introduced in this study proves that in patients with Fournier's gangrene, the extent of the gangrene as well as the patient's age and physiological status have a significant effect on the outcome.

Temporary abdominal closure with the vacuum pack technique: a 5-year experience.

UNLABELLED: The vacuum pack technique is used increasingly for temporary abdominal closure. This paper communicates the related experience of the authors. MATERIAL AND METHODS: The charts of 74 patients who underwent temporary abdominal closure with the vacuum pack technique between January 2000 and December 2005 were reviewed retrospectively. The demographic characteristics, mortality rates and long-term complications were analysed. RESULTS: The vacuum pack was inserted 139 times to 74 patients who required temporary abdominal closure. The mortality rate was 60% (45/74). Survivors and non-survivors did not differ significantly with respect to etiology (traumatic vs. non-traumatic), age, number of re-laparotomies, hospital stay, type of closure (primary or with a graft). The frequency of primary fascial closure was 45%. The frequency of incisional hernia was 50% in the patients who underwent primary closure and 10% in those who underwent graft placement (p < 0.05). CONCLUSIONS: Temporary abdominal closure with the vacuum pack is a simple and inexpensive technique. Primary fascial closure is possible in approximately half of the cases ; however, the frequency of incisional hernia is high.

Performance of emergency medicine residents in the interpretation of radiographs in patients with trauma.

BACKGROUND: Radiographs are vital diagnostic tools that complement physical examination in trauma patients. A study was undertaken to assess the performance of residents in emergency medicine in the interpretation of trauma radiographs. METHODS: 348 radiographs of 100 trauma patients admitted between 1 March and 1 May 2007 were evaluated prospectively. These consisted of 93 cervical spine (C-spine) radiographs, 98 chest radiographs, 94 radiographs of the pelvis and 63 computed tomographic (CT) scans. All radiological material was evaluated separately by five emergency medicine residents and a radiology resident who had completed the first 3 years of training. The same radiographs were then evaluated by a radiologist whose opinion was considered to be the gold standard. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: The mean (SE) age of the patients was 29 (2) years (range 2-79). There were no statistically significant differences in terms of pathology detection between the emergency medicine residents and the radiologist. The agreement between the emergency medicine residents and the radiology resident was excellent for radiographs of the pelvis and the lung (kappa (kappa) = 0.928 and 0.863, respectively; p<0.001) and good for C-spine radiographs and CT scans (kappa = 0.789 and 0.773, respectively; p<0.001). CONCLUSIONS: Accurate interpretation of radiographs by emergency medicine residents who perform the initial radiological and therapeutic interventions on trauma patients is of vital importance. The performance of our residents was found to be satisfactory in this regard.

Relationships between markers of inflammation, severity of injury, and clinical outcomes in hemorrhagic shock.

This study was performed to investigate the relationships between markers of inflammation in serum (interleukin-6 [IL-6], interleukin-10 [IL-10], and granulocyte elastase [GE]), severity of injury, and clinical outcomes, and to evaluate the predictive value of these markers for major complications and mortality. This study, which was conducted between August 2003 and May 2005, examined patients older than 16 y who were admitted to the Emergency Unit of the Uludag University Medical School within 12 h after trauma, and who had traumatic hemorrhagic shock (THS) at admission. Three groups were established: the THS group (n=20), the pure hemorrhagic shock (PHS) group (n=20), and the healthy control group (n=20). Demographic data were recorded for all subjects, and blood samples were taken for lactate, base excess, GE, IL-6, and IL-10 measurements. The Glasgow Coma Score, the Revised Trauma Score, the Injury Severity Score, the New Injury Severity Score, and the Trauma Score-Injury Severity Score were calculated; complications and final clinical outcomes were monitored. A total of 35 men and 25 women were included in the study; mean patient age was 41+/-17 y. In the THS group, scores were as follows: Revised Trauma Score, 10.2+/-2.2; Trauma Score-Injury Severity Score, 0.86+/-0.2; Injury Severity Score, 24.8+/-9.0; and New Injury Severity Score, 32.7+/-9.0. IL-6, IL-10, lactate, and base excess levels in the THS group were significantly higher than those in the PHS and healthy control groups. The serum GE level of the THS group was significantly higher than that of the healthy control group, but it did not differ significantly from that of the PHS group. Complications such as sepsis, acute respiratory distress syndrome, and multiple organ failure occurred in 50% of the THS group and in 20% of the PHS group. Mortality was 30% in the THS group and 10% in the PHS group. In the THS group, no significant differences were noted between markers of inflammation and trauma scores of patients who died and those who survived. The investigators concluded that although the levels of markers of inflammation increased in THS patients, they were inadequate for predicting mortality and the development of complications such as acute respiratory distress syndrome, multiple organ failure, and sepsis. A larger study based on the use of serial marker measurements is warranted.

Childhood falls: characteristics, outcome, and comparison of the Injury Severity Score and New Injury Severity Score.

OBJECTIVES: The aim of this study was to determine the general characteristics of childhood falls, factors affecting on mortality, and to compare the Injury Severity Score (ISS) and the New Injury Severity Score (NISS) as predictors of mortality and length of hospital stay in childhood falls. METHODS: We retrospectively analysed over a period of 8 years children aged younger than14 years who had sustained falls and who were admitted to our emergency department. Data on the patients' age, sex, type of fall, height fallen, arrival type, type of injuries, scoring systems, and outcome were investigated retrospectively. The ISS and NISS were calculated for each patient. Comparisons between ISS and NISS for prediction of mortality were made by receiver operating characteristic (ROC) curve and Hosmer-Lemeshow (HL) goodness of fit statistics. RESULTS: In total, there were 2061 paediatric trauma patients. Falls comprised 36 (n = 749) of these admissions. There were 479 male and 270 female patients. The mean (SD) age was 5.01 (3.48) years, and height fallen was 3.8 (3) metres. Over half (56.6%) of patients were referred by other centres. The most common type of fall was from balconies (38.5%), and head trauma was the most common injury (50%). The overall mortality rate was 3.6%. The cut off value for both the ISS and NISS in predicting mortality was 22 (sensitivity 90.5%, specificity 95.4% for ISS; sensitivity 100%, specificity 88.7% for NISS) (p>0.05). Significant factors affecting mortality in logistic regression analysis were Glasgow Coma Scale (GCS) <9, ISS >22, and NISS >22. There were no significant differences in ROC between three scoring systems. The HL statistic showed poorer calibration (p = 0.02 v p = 0.37, respectively) of the NISS compared with the ISS. CONCLUSIONS: In our series, the head was the most frequent site of injury, and the most common type of fall was from balconies. Scores on the GCS, NISS, and ISS are significantly associated with mortality. The performance of the NISS and ISS in predicting mortality in childhood falls was similar.

Tau protein as a serum marker of brain damage in mild traumatic brain injury: preliminary results.

The objective of this study was to investigate the diagnostic value of serum tau protein in determining the severity of traumatic brain injury in patients with mild traumatic brain injury (mTBI) and high-risk patients. Adult patients who presented to our emergency department (ED) with mTBI over 1 year were prospectively enrolled. Patients underwent cranial computed tomography (CT) and were subdivided into high- and low-risk groups, according to the probability of resultant intracranial injury. Serum tau levels of 60 patients and 20 healthy volunteers, who served as a control group, were measured. The mean age of the 60 patients (45 males, 15 females) was 32.5 years (range, 15-66 y). Mean Glasgow Coma Scale (GCS) score was 14+/-0.6. CT scans demonstrated intracranial injury in 11 patients (18.3%) and depressed fracture in 4 patients (6.7%). Serum tau levels of patients (188+/-210 pg/mL), compared with those of controls (86+/-48 pg/mL), were relatively higher; however, differences were not statistically significant (P=.445). Also, serum tau levels of high-risk patients (307+/-246 pg/mL) were significantly higher than those of low-risk patients (77+/-61 pg/mL) (P=.001). A total of 48 patients (80%) were accessible for follow-up after 6 months. Postconcussive syndrome was observed in 8 patients, 5 of whom had serum tau protein levels that were higher than those of the other 3 patients. However, no statistically significant difference was observed (P>.05). Investigators of the present study noted that serum tau levels in patients with mTBI were increased. Therefore, it is believed that this biomarker may prove helpful in identifying high-risk patients with mTBI. However, additional studies are needed to establish the diagnostic value of serum tau in detecting traumatic brain injury in patients with mTBI.

Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake.

OBJECTIVES: This study aimed to provide an overview of morbidity and mortality among patients admitted to the Hospital of the Medicine Faculty of Uludag University, Bursa, Turkey, after the 1999 Marmara earthquake. METHODS: Retrospective analysis of the medical records of 645 earthquake victims. Patients' demographic data, diagnosis, dispositions, and prognosis were reviewed. RESULTS: A total of 330 patients with earthquake related injuries and illness admitted to our hospital were included and divided into three main groups: crush syndrome (n = 110), vital organ injuries (n = 57), and non-traumatic but earthquake related illness (n = 55). Seventy seven per cent of patients were hospitalised during the first three days after the earthquake. The rate of mortality associated with the crush syndrome, vital organ injury, and non-traumatic medical problems was 21% (23/110), 17.5% (10/57), and 9% (5/55), respectively. The overall mortality rate was 8% (50/645). CONCLUSIONS: In the first 24-48 hours after a major earthquake, hospital emergency departments are flooded with large numbers of patients. Among this patient load, those patients with crush syndrome or vital organ injuries are particularly at risk. Proper triage and prompt treatment of these seriously injured earthquake victims may decrease morbidity and mortality. It is hoped that this review of the challenges met after the Marmara earthquake and the lessons learned will be of use to emergency department physicians as well as hospital emergency planners in preparing for future natural disasters.

[The analysis of traumatized patients who were admitted to the Uludag University Medical School Hospital after the Marmara earthquake]. / Marmara depremi sonrasi Uludag Universitesi Tip Fakültesi hastanesine basvuran travmali olgularin analizi.

The aim of this study was to analyze the victims of the Marmara earthquake who injured, especially had the crush syndrome. Our hospital received a total of 645 victims after the earthquake and admitted 330. Victims were classified into five different groups according to their diagnosis (crush syndrome, vital organ injury, vertebral and pelvic injuries, others and unknown) and their mortality rates were determined. Mortality was highest (21%) in the crush syndrome group. Second and third highest mortality were in the unknown (20%) and vital organ injury (20%) groups. The overall mortality rate was 8%. In conclusion the earthquake victims with crush syndrome and vital organ injury had the highest mortality and morbidity rates. Because of that so many departments (General Surgery, Emergency Medicine, Orthopedics Surgery, Plastic Surgery, Nephrology, Infection Disease etc.) had to be study in a great harmonious.

Outcome of major trauma in a Turkish university hospital: did integrated approach make a difference?

The aim of this study was to determine the effect of the institution in an in-hospital integrated approach to trauma on the mortality of severely injured patients in a university hospital in Turkey. We examined the effects of several risk factors, namely physiological parameters, anatomical findings, and the timeliness of therapeutic approaches, on the mortality of major trauma patients before and after the institution of integrated trauma care. The investigated risk factors were injury severity score (ISS), revised trauma score (RTS), anatomical localization of the injury, the type of injury, prehospital time, emergency room time, and referral from another hospital. TRISS (RTS, ISS, and age combination index) analysis was done for each patient and the M-, Z-, and W-statistics were calculated. Mortality in the low RTS and the penetrating injury groups decreased significantly. The overall mortality decreased from 32.5% to 23.3%. There were three unexpected survivors in the second period, but there were no unexpected survivors in the first period. Twenty-six of the first period and nine of the second period deaths were unexpected. A significant improvement was seen in the Z-statistics between the two periods. Z value increased from -2.47 to 0.55. In-hospital integrated approach to trauma made major improvements in the care of the patients with severe injuries, especially those with significant airway, ventilation and circulation problems.

Financial burden of trauma care on a university hospital in a developing country.

BACKGROUND: Trauma care is expensive and more so for the hospitals not subsidized by the government, as is the case in developing countries. In this study, the burden of trauma care on a typical Level I trauma center in Turkey was investigated. METHODS: Medical, demographic, and financial records of trauma patients who were hospitalized in the calendar year of 1996 were analyzed. RESULTS: A total of 347 patients had complete data available for analysis. The mean Injury Severity Score was 13.3+/-0.5. Total hospital charges and charges per patient were $547,391 and $1,577, respectively. There was a positive correlation between the Injury Severity Score and the hospital charges. Although 54.2% of the patients were self-payer and the rest (45.8%) had some form of a health insurance, 5.5% ($30,496) of total hospital charges of these 347 trauma patients could not be collected by the hospital. CONCLUSION: Trauma care is expensive and reimbursement is not always possible, but the hospital's nonreimbursed money was within tolerable limits, and the overall financial balance of the hospital from the trauma care was on the positive side, even in the absence of government subsidy.

L-glutamine enemas attenuate mucosal injury in experimental colitis.

PURPOSE: The aim of this study was to investigate the role of 1-glutamine, short chain fatty acid, prednisolone, and mesalazine (5-aminosalicylic acid) enemas on mucosal damage and inflammation in experimental colitis. METHODS: Colitis was induced in rats with trinitrobenzene sulfonic acid in ethanol. Saline (n = 14), prednisolone (n = 13), 5-aminosalicylic acid (n = 14), 1-glutamine (n = 14), and short chain fatty acid (n = 13) enemas were applied twice daily to the rats for seven days after the induction of colitis. The sham group (n = 9) received only saline enemas. Rats were killed at the seventh day and their colonic macroscopic inflammatory scores were determined. Colonic mucosal gamma glutamyl transpeptidase activity and colonic mucosal malondialdehyde levels were measured. The same measurements but no enemas were done in the control group (n = 7). RESULTS: There were significant differences in macroscopic inflammatory scores between sham and colitis groups (P < 0.001). The macroscopic inflammatory scores of the colitis group were higher than the short chain fatty acid and glutamine groups (P < 0.05). Whereas the mucosal gamma glutamyl transpeptidase activity was diminished in prednisolone, 5-aminosalicylic acid, and short chain fatty acid groups when compared with the control group; in the colitis, sham, and glutamine groups the activity of this enzyme did not change. The mucosal malondialdehyde levels were significantly lower in the prednisolone and glutamine groups than in the colitis group. CONCLUSION: Only one of four agents tested, namely, 1-glutamine enemas, could decrease the severity of colitis both morphologically and biochemically. Moreover, L-glutamine prevented the colitis-induced oxidant injury in the colonic mucosa. On the other hand, prednisolone and short chain fatty acids seemed to improve only the physiologic changes of colitis.

Is it necessary to retrieve dropped gallstones during laparoscopic cholecystectomy?

BACKGROUND: An experimental study was planned to evaluate the effect of bile alone and bile in combination with gallstones on intraperitoneal adhesion and abscess formation in the peritoneal cavity of the rat. METHODS: One hundred Sprague-Dawley rats were assigned to ten groups (n: 10). Groups 1-3 received a 1-ml intraperitoneal injection of saline, sterile bile, and infected bile. Groups 4-10 underwent a lower 5-mm midline abdominal incision. In groups 5, 7, and 9, a single gallstone (3-mm diameter) was placed in the right upper quadrant and injected with sterile saline, sterile bile, and infected bile, respectively. In groups 6, 8, and 10, four gallstones (3-mm diameter) were placed in the right upper quadrant together with sterile saline, sterile bile, and infected bile, respectively. Group 4 only underwent a 5-mm midline incision. All animals were sacrificed at the end of 4 weeks and the peritoneal cavity was carefully examined to investigate adhesions and abscess formation. The adhesions were graded according to Nair's gross pathologic grading of adhesions. The Kruskal-Wallis nonparametric test (KW) was used for statistical analysis. RESULTS: No intraabdominal lesions were noted in groups 1-3. The adhesion score was increased by number of stone and infected bile (G4: 3, G5: 3, G6: 11, G7: 7, G8: 10, G9: 15, G10: 18). But there was only a significant difference between the groups that received sterile saline+single stone (G5) and that receiving infected bile+four stones (G10) (KW: 24.3 P < 0.05). There was abscess formation in three rats in group 9 and two in group 10. CONCLUSIONS: In conclusion, infected bile in combination with multiple stones increases the gross grading of adhesion and intraabdominal abscess formation. Thus, in cases with multiple stones and infected bile, the dropped stones should be retrieved and the peritoneal cavity should be copiously irrigated during laparoscopic cholecystectomy.

The value of herniography in football players with obscure groin pain.

From January 1985 to May 1994, herniography was performed in 60 football players with groin pain but without clinical signs of hernia. Herniographic examination revealed 62 occult inguinal hernias in 51 cases, nine cases were normal. Fifty of these 51 cases were operated on. Surgery was postponed until the end of the league in one case. There was only one false positive examination. The herniographic and operative diagnoses corresponded well in the other 49 cases. There were three minor complications which have related to the needle sigmoid colon puncture, all of them were managed conservatively. There was no technical failure. These results indicate that herniography is a safe and valuable method to identify non palpable herniations causing groin pain of unknown origin in football players.

Effect of CO2 pneumoperitoneum on bacteremia in experimental peritonitis.

Bacteria transfer to the blood from the peritoneum is thought to be augmented when the diaphragmatic stomata are activated by an increased intra-abdominal pressure. Therefore, it may be expected that the increase in intra-abdominal pressure during laparoscopic surgery can augment the absorption of bacteria from the peritoneum to the blood. The present study examines the effect of pneumoperitoneum on bacteremia in experimental Escherichia coli peritonitis in rabbits. Twenty-four rabbits were divided into three groups. 10(9) colony forming units of E. coli were inoculated intraperitoneally into group 1 (n = 8). Group 2 (n = 8) received an identical bacterial inoculum and underwent a midline laparotomy at the 2nd hour. Group 3 (n = 8) also had an identical bacterial inoculum which was followed by 15 mm Hg CO2 pneumoperitoneum for 1 h at the 2nd hour. In all groups, the growth value (GV) was measured in the 3rd- and 6th-hour blood cultures using the Bactec NR 730 system. There was no difference in the 3rd- and 6th-hour GVs (p > 0.05) among the three groups. In conclusion, pneumoperitoneum with 15 mm Hg CO2 in experimental E. coli peritonitis did not increase the bacteremia when compared with the control and laparotomy groups.

Colorectal cancer in young adults.

The study was carried out to promote a greater awareness of the potential for colorectal cancer in young adults under 40 years of age. During the 8 years between 1986 and 1993, 237 patients with adenocarcinoma of the colon and rectum were operated at the Uludag University Hospital. Of these 237 cases, 46 patients under 40 years old were reviewed retrospectively. They accounted for 19.4% of the total number of patients with carcinoma of the colon and rectum operated during the same period. Rectal bleeding was the most common presenting symptom. The mean duration of time from the onset of symptoms to diagnosis was 5.8 months. The rectosigmoid area was the most frequently involved site (80%). Seventy-six percent of the patients had Dukes' stage C or D tumors. Forty-eight percent of the tumors were either poorly differentiated or mucinous. The cumulative survival rate at 5 years was 43.4%. Patients under 40 years old with carcinoma of the colon and rectum are usually symptomatic and have advanced disease at the time of presentation. Although colorectal cancer is usually a disease of older patients it is becoming more common in younger populations.