A clinical forensic scientist in the burns unit: necessity or not? A prospective clinical study.

Child abuse by burning is a common means of assault that may be difficult to prove. Even though well trained in burns management physicians on the burn team may not be sufficiently qualified to clarify the medicolegal aspects of the incident. In Turkey, physicians have a responsibility to notify the law offices of injury to children caused by any non-accidental mechanism including neglect. The consequences of false positive and/or false negative reports to the legal offices may be damaging for the care-takers and/or the children. In our study, 239 consecutively hospitalized children with burns were studied prospectively. A clinical forensic scientist and a physician of the burns team interpreted incidents separately so that neither had an idea about the other's diagnoses until the end of the study. There were found to be some differences in the interpretation of the incidents by the clinical forensic scientist and the burns team physician. These differences were described as discordant diagnoses. The physician accepted 99 (41.4%) of the incidents as an accident while only 66 (27.6%) of the victims were labelled as accidents by the forensic scientist. A multivariate analysis identified low socioeconomic status, aged between 3 and 6 years, and a family size of more than six as independent variables significantly associated with discordant diagnoses (p = 0.0388, 0.0001, 0.0203, respectively). As a conclusion, we suggest that to minimize the likelihood of a legally inaccurate diagnosis, a clinical forensic scientist seems to be necessary in the emergency department.

Thyroid incidentalomas: prediction of malignancy and management.

The treatment strategy of an incidentally detected thyroid nodule is controversial. The aim of this study was to establish management criteria for thyroid incidentalomas by defining and formulating the risk factors predicting thyroid malignancy. A prospective database containing 815 consecutive patients who underwent a thyroidectomy for nodular thyroid disease, between January 1992 and May 2003, was studied. Multivariate analyses demonstrated that the independent clinical predictors of malignancy were a fixed nodule and cervical lymphadenopathy on palpation, a euthyroid patient, and a patient age <23 years or >45 years; and independent nodule features significantly associated with malignancy were punctuate calcifications, irregular nodule margin, solid appearance on ultrasonography, and solitary nodule in an euthyroid patient. Using the regression coefficients of four independent ultrasound (US) features, a malignancy risk score of a nodule was calculated as follows. Depending on the score of a thyroid nodule, a simple follow-up, a US-guided fine needle aspiration biopsy or a thyroidectomy, may be offered for management.

A simple scoring system to evaluate the effects of cold ischemia on marginal liver donors.

BACKGROUND: Exactly what constitutes a marginal donor remains ill defined. The authors set out to create a scoring system that objectively classifies a donor as marginal or nonmarginal and to define what the maximum acceptable preservation period is for the marginal liver to minimize early graft dysfunction. METHODS: The authors performed an analysis on data collected prospectively of 397 cadaveric liver transplants. Both univariate and multivariate analyses were performed on donor, recipient, and perioperative factors with relation to early allograft dysfunction. A score was developed that classified donors into marginal and nonmarginal populations, and the influence of cold ischemia was determined for each group. RESULTS: Multivariate analysis-determined donor age and steatosis (moderate to severe) were independent predictors of deranged function. This enabled the authors to produce a scoring system to differentiate marginal donors with respect to risk of early allograft dysfunction as follows: Formula=(20.06xsteatosis)+(0.44xdonor age), cutoff 23.1. In the marginal group, the cutoff value of cold ischemia time was 12.6 hr. CONCLUSIONS: The authors developed a scoring system that classified an organ as marginal or nonmarginal depending on the donor age and degree of steatosis. Marginal livers have a strong risk of developing early allograft dysfunction with increasing cold ischemia times and should be transplanted within 12 hr. Cold ischemia time was not found to be an important factor in the development of early allograft dysfunction in nonmarginal donors.

Long-term survival is improved by an extended lymph node dissection in potentially curable gastric cancer.

BACKGROUND/AIMS: This study was planned to investigate the therapeutic value of performing an extended lymphadenectomy in potentially curable gastric cancer. METHODOLOGY: A prospective gastric cancer database was used. In total 114 gastric cancer patients (85 male, 29 female) who underwent a gastrectomy for curative intent from 1992 through 1999 were included to this study. Morbidity and mortality, survival rates and factors affecting survival were evaluated. RESULTS: Sixty-six (58%) patients had limited (D1) and 48 (42%) patients had extended (D2) gastric resections. The operative mortality rates were 12% and 8% and the postoperative complication rates were 33% and 25% in the D1 and D2 lymphadenectomy patients, respectively. The mean follow-up period was 34 (range: 8-94) months. The overall mean survival was 32 months (25 months in D1 group, 46 months in D2 group) (P < 0.05). The duration of symptoms, the presence of postoperative complications, the extent of lymphadenectomy, the operative curability and the site of the tumor were all found to be independent prognostic factors based on a multivariate analysis. CONCLUSIONS: This study demonstrates that an extended lymph node dissection improves long-term survival without increasing postoperative morbidity and mortality in patients with potentially curable gastric cancer.

A prognostic score for colorectal cancer.

BACKGROUND/AIMS: Scoring systems are generally used for predicting prognosis in critically ill patients, but not frequently for predicting prognosis in cancer. Our aim was to develop a prognostic score for colorectal cancer. METHODOLOGY: Demographic, clinical, laboratory, radiologic, histopathologic and operative data of 112 patients who had resection for colorectal cancer, were analyzed for their effect on survival. Eight variables (invasion depth of tumor, nodal status, presence of metastasis, CEA level, differentiation, resectability, tumor location, presence of blood transfusion), which have the most significant effect on survival in univariate analysis and multivariate analysis, were chosen. Coefficients were calculated and the Prognostic Score for Colorectal Cancer (PSCRC) was designed. All patients were scored using this system and staged according to TNM, Dukes and Astler-Coller systems. RESULTS: The score range is between -49 and 80. Patients were grouped as Group 1 (score < -30), Group 2 (score -30 to -6), Group 3 (score -5 to 19), Group 4 (score > 19). Survival rates decreased and recurrence rates increased significantly with increasing scores. The associations of PSCRC and staging systems with survival and recurrence rates were determined by logistic and Cox regression analyses. PSCRC was proved to have the most significant association with survival and recurrence rates. Furthermore, PSCRC had better correlation with survival and recurrence rates when compared with staging systems according to Pearson correlation analysis. CONCLUSIONS: Inclusion of more variables in PSCRC seems to make it superior to the staging systems. PSCRC may be a practical and useful scoring system in clinical practice and is easily adapted to different patient populations.

The effects of ciprofloxacin and ursodeoxycholic acid on bacterial translocation in obstructive jaundice.

BACKGROUND/AIMS: We aimed to search the effects of two different drugs in bacterial translocation, both in combination and alone: ursodeoxycholic acid, the effectiveness of which was evidenced previously, and ciprofloxacin, which had not been used before, in an experimental obstructive jaundiced rat model. METHODS: Fifty Wistar Albino rats were divided into five groups: sham group (A), control group (B), ciprofloxacin group (C), ursodeoxycholic acid group (D), and ciprofloxacin + ursodeoxycholic acid group (E). Except in Group A animals, the common bile ducts in all animals were ligated. Hematological, microbiological and histopathological changes were compared between the groups. RESULTS: White blood cell counts were elevated in all common bile duct-ligated test subjects. The median white blood cell count in Group B was significantly higher than that in Group D and Group E (p=0.022 and p=0.037, respectively). There was no significant difference between the control group and the study groups in terms of biochemical changes. Blood cultures were negative in Group A and Group E. The positive blood culture rate in Group B was significantly higher than in Groups A and E (p<0.05). Positive mesenteric lymph node culture rate was significantly lower in Group E than in the control group (p=0.026). In the histopathological evaluation, there was no difference in the morphology of the terminal ileum between the groups, but Group E animals had significantly less inflammatory cells in the intestinal wall compared to Group C and D animals. CONCLUSIONS: Ciprofloxacin and ursodeoxycholic acid have a synergic effect on prevention of bacterial translocation in obstructive jaundice.