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

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

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

El cuadro denominado metopismo consiste en lapersistencia parcial o total de la sutura que se extiendedesde el nasion hasta el ángulo anterior del bregma. Eltiempo de cierre de la sutura metópica oscila desde elmomento del nacimiento hasta los ocho años. El criteriomás aceptado es que el cierre suele terminar a losdos años. Algunos estudios mencionaban la posibilidadde la persistencia de dicha sutura a lo largo de toda lavida, pero es excepcional en la práctica clínica. Se presentaun caso de traumatismo de 43 años de edad, quemostraba en la radiología la falta de cierre de dichasutura metópica. Aunque puede considerarse comouna anomalía rara, también puede con una fracturavertical frontal, cercana a la línea media, en pacientescon traumatismos. Por lo tanto, el cirujano debe percatarsede este hecho anatómico en la atención inicialdel paciente y en la planificación de una craneotomíabifrontal. En este trabajo se señala que la reconstruccióntridimensional de la TAC añade una informaciónvaliosa al estudio radiológico convencional en la unidadde urgencias

Metopism is partially or totally persisting sutureextending from the nasion to the anterior angle of thebregma. The time of physiological closure of the metopicsuture varies from birth to 8 years of age. Widelyaccepted closuring time is approximated at 2 years ofage. Although formerly reported skull studies mentionedthe persistent metopic suture, it is extremely rarein clinical practice. We presented a trauma case of 43years of age who was demonstrated radiologically tohave a persisting suture. Persistent metopic suture maybe misdiagnosed as a vertical traumatic skull fractureextending in the mid-line in head trauma patients.Therefore the surgeon should be aware of this anatomicalcondition in the primary and secondary surveillanceof the traumatized patient and during surgicalintervention including especially frontal craniotomy.Reconstructed tomography scan demonstrating suturalclosuring status may provide additional informativevalue in the diagnostic sequence superior to plain X-rayin the emergency setting

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

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

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

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

Surgeons' attitudes toward HIV/AIDS in Turkey.

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

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

AIM: To evaluate the effects of Teicoplanin and/or Granulocyte-Colony Stimulating Factor (G-CSF) on survival in an experimental model of MRSA pneumonia. MATERIAL AND METHOD: Seventy five Swiss Albino mice weighing 35 gr (32-43) were used. 50 microl of clinical isolate of MRSA (3 x 10(8) CFU/ml in saline solution) was administered by tracheal puncture to neutropenic mice. Neutropenia was achieved by using Cyclophosphamide 200 mg per kg intraperitoneally. The groups were consisted of tracheal puncture control in neutropenic mice (group 1) (n = 15), pneumonia in neutropenic mice (group II) (n = 15), Teicoplanin therapy for pneumonia in neutropenic mice (group III) (n = 15), G-CSF therapy for pneumonia in neutropenic mice (group IV) (n = 15), Teicoplanin and G-CSF combined therapy for pneumonia in neutropenic mice (group V) (n = 15). Differences in the survival rates within 72 hours among the groups, microbiological analysis of various tissue samples were accomplished and white blood cell counts were obtained. Kaplan-Meier statistics was used for survival analysis. Subgroup comparisons were done by using Breslow statistics. RESULTS: Teicoplanin therapy increased the survival rate (p = 0.0001) whereas G-CSF therapy did not in comparison to other groups. Teicoplanin and G-CSF combination therapy improved survival rate when compared with groups II, III, IV (p = 0.0001, p = 0.003, p = 0.0001, respectively). CONCLUSION: Teicoplanin and G-CSF combination therapy seems effective in reducing mortality rates in MRSA pneumonia in an experimental setting. Further animal and clinical studies must be done to achieve success in the treatment of nosocomial MRSA pneumonia.

Train-pedestrian accidents.

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

Effects of CO2 insufflation and laparotomy on wound healing in mice.

BACKGROUND: The aim of the present study was to evaluate the effects of laparotomy and CO2 insufflation on wound healing in a murine incisional wound healing model. METHODS: Seventy-two male Swiss Albino mice were randomly allocated into three groups of control, laparotomy and CO2 insufflation. A transverse skin incision of 15 mm was made in the dorsum of each mouse, and four interrupted mattress sutures with 4.0 polypropylene thread were laid for wound closure. A median laparotomy was performed in the laparotomy group. CO2 insufflation was performed with an intra-abdominal pressure of 9 mmHg. The retained gas was evacuated from the abdominal cavity at the end of a 60-min period. Mice were killed on the 3rd, 7th and 15th postoperative days. The wound tensile strength and 5-hydroxyproline concentration in the wound tissue were measured. RESULTS: Tensile strength of the incised skin increased as the post-incision period progressed. There was no significant difference between the tensile strengths of the incised skin of control, laparotomy and CO2 insufflation groups throughout the observation period. The skin 5-hydroxyproline concentrations of all groups were not significantly different at the 3rd postoperative day. But laparotomy and CO2 insufflation groups had lower 5-hydroxyproline concentrations at the 7th and 15th postoperative days, when compared to controls (P < 0.02 for 7th and 15th days). CONCLUSION: CO2 insufflation and laparotomy reduce the 5-hydroxyproline concentration of the wound, suggesting a diminished wound healing capacity.

Spontaneous hepatic rupture in pregnancy.

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

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

PURPOSE: The effect of GM-CSF (granulocyte macrophage-colony stimulating factor) on tissue necrosis and ulceration induced with doxorubicin extravasation was studied. MATERIALS AND METHODS: Adult Wistar-Albino rats (n=36) were used in the study. Doxorubicin (0.4mg/300 g) was applied subcutaneously to abdominal wall. In group I (n=18), half hours after doxorubicin injection, GM-CSF 6 microg/300 mg was applied subcutaneously to the same localization. In group II (n = 18) same amount of physiologic saline (0.5 ml) were given subcutaneously to the injection site (as vehicle control groups). Group II and I were examined for induration or ulceration on 7th and 21st day. After evaluating the lesions, the injection sites were excised. Hydroxyproline (5-HP) values of dry tissue samples were calculated and histopathologic examination was done. RESULTS: At day seven there were four and eight ulceration in groups I and II, while there were four and 14 ulceration in the second evaluation at day 21st (p<0.05). 5-HP values of the groups were as follows. 97.43+/-20.39 in group land 91.34+/-22.26 in group II. Although there was an increase in epithelization, eosinophil and lymphocyte infiltration and mast cell number in group I in histopathologic examinations only the increase in angiogenesis in group I was found to be statistically significant (p<0.05). CONCLUSION: It can be concluded that GM-CSF may have beneficial effect in the treatment of doxorubicin induced tissue necrosis.

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

AIM: The aim of this retrospective study was to evaluate the factors on mortality in urban free vertical falls. PATIENTS AND METHODS: A total of 180 urban vertical free fall victims who survived transport to the emergency room between the period of 1980-1998 were evaluated. Minor bruises, abrasions, haematomas, and soft tissue injuries were not encountered. Serious injuries such as bone fractures, liver lacerations, epi-subdural haematomas, haemothorax, haemomediastinum, retroperitoneal haematomas were evaluated. RESULTS: Of the total, 23% (n = 41) of patients were female and 73% (n = 139) were male. The mean age was 22.3 years (4-75 years). Extremity fractures were found in 6.7% (n = 12), cranial trauma in 14.4% (n = 26), thoracic trauma in 2.2% (n = 4) retroperitoneal trauma in 2.8% (n = 5), vertebral column trauma in 1.7% (n = 3) of cases. The overall number of the pathologies was 59. In-hospital mortality was 8.9% (n = 16). The injury severity scores (ISSs) of non-survivors and survivors were 33 +/- 4, and 5 +/- 0.6, respectively (P = 0.0001). The heights fallen were 8.6 +/- 2.3 m for non-survivors and 5.2 +/- 0.2 m for survivors (P = 0.022). The mean ages of non-survivors and survivors were 41.6 +/- 5.9 years and 20.4 +/- 1.2 years, respectively (P = 0.003). Serious cranial trauma was found in 68.7% (n = 11) and 9.1% (n = 5) of non-survivors and survivors, respectively (P = 0.0001). Extremity trauma was encountered in 31.2% (n = 5) and 4.2% (n = 7) of non-survivors and survivors, respectively (P = 0.0015). The ISSs were 6.8 +/- 1.0 and 8.9 +/- 1.1 for cases under the age of 6 years and others, respectively (P = 0.15). Using logistic regression analysis, ISS, height and age were found to be significant factors in mortality. CONCLUSION: Vertical deceleration injury represents a distinct form of trauma. With the results of this study, it can be concluded that ISS, height and age are significant factors in determining the severity of trauma.

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

OBJECTIVE: To assess the effects of laparotomy, and insufflation of carbon dioxide and air, on the immune system in rats. DESIGN: Randomised laboratory study. SETTING: Teaching hospital, Turkey. ANIMALS: 77 Wistar rats randomly allocated to 2 groups one of which was sensitised with dinitrofluorobenzene (DNFB, n = 43) and one of which was not (n = 34). INTERVENTIONS: The DNFB group was sensitised and subdivided into control (n = 8), laparotomy alone (n = 7), and insufflation with carbon dioxide (CO2) for 30 and 60 mins (n = 7 in each) or room air for 30 and 60 mins (n = 7 in each). A week later DNFB was reapplied to the ears. In the group not sensitised with DNFB the animals were subdivided similarly, the corresponding numbers in each group being, 6, 6, 6, 6, 5, and 5. MAIN OUTCOME MEASURES: Delayed type hypersensitivity (DTH) measured by ear swelling in the DNFB group, and peritoneal bactericidal activity, total free peritoneal cell counts (TPC), and cell types in the non-sensitised group. RESULTS: There were significant differences in the degree of ear swelling in the DNFB group between control and laparotomy groups (p = 0.0001) and between control and both insufflations of air (p = 0.002 and p = 0.0003, respectively). In the non-sensitised group peritoneal bactericidal activity was significantly increased after 7 hours in the 60 mins air insufflation group (p = 0.04). At 24 hours there were no differences among the groups. TPC were not affected. The number of peritoneal polymorphonuclear leucocytes (PMN) was significantly higher in the laparotomy alone group than in the control or any of the insufflation groups (p < 0.05). CONCLUSIONS: Laparotomy and air insufflation depressed cell-mediated immunity. Peritoneal bactericidal activity was affected only after 60 minutes of air insufflation.

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

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