Comparison of Uncultured Cell Spray and Split-Thickness Skin Grafting in Deep Partial-thickness Burns: A Novel Animal Model.

OBJECTIVE: To compare uncultured cell spray and conventional surgery in deep second-degree burns in rats and create an experimental model for the use of this method. STUDY DESIGN: An experimental study. Place and Duration of the Study: Hacettepe University Experimental Animals Application and Research Center, Ankara, Turkey, from October 2018 to December 2020. METHODOLOGY: Twenty-four Wistar albino rats were divided into 4 groups. Two deep second-degree burns were created on the dorsal skin in different locations. On the 5th day of the burn wound, a split-thickness skin graft was applied to one of the burn wounds with half of the donor graft. Two-stage enzyme application was performed on the other half of the donor graft and keratinocytes were applied as a spray to the other tangential excision burn wound. Samples taken by excisional biopsy on certain days were examined macroscopically and histologically. RESULTS: In all the experimental groups according to sacrification days, macroscopic healing percentages, non-epithelised areas, inflammation and neovascularisation scoring were similar between graft side and spray side. CONCLUSION: The effects of conventional split-thickness skin graft and uncultured cell spray on wound healing were comparable, suggesting that the uncultured cell spray method can be used as an alternative method to the classical burn treatment. KEY WORDS: Deep second-degree burn, Grafting, autologous cell, Non-cultured cell spray, Keratinocyte.

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study.

INTRODUCTION: Gait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI. METHODS: This matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n=28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n=14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n=14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index. RESULTS: The baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p=0.01, p=0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p=0.004), swing (p=0.006), stance (p=0.008) and velocity (p=0.001), cadence (p=0.001), TUG (p=0.001), kinesiophobia (p=0.001) and pain (p=0.001) in the overground group. Statistically significant differences were determined in step length (p=0.01), swing (p=0.01), stance (p=0.02) and velocity (p=0.001), cadence (p=0.001), TUG (p=0.001), kinesiophobia (p=0.001) and pain (p=0.001) in the treadmill group, when pre and post-training values were compared. CONCLUSIONS: The results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI. CLINICAL TRIAL REGISTRATION NUMBER: NCT03217526.

Vestibular landmarks to minimize injury to the mental nerve during transoral endoscopic thyroidectomy-vestibular approach (TOETVA) procedure: an anatomical study / Puntos de referencia vestibulares para minimizar la lesión del nervio mentoniano durante el procemiento de abordaje vestibular de tiroidectomía endoscópica transoral (TOETVA): un estudio anatómico

SUMMARY: The aim of this study is to reveal the morphometry of the mental nerve to describe a safe zone for minimizing mental nerve damage during transoral endoscopic thyroidectomy-vestibular approach (TOETVA). This study was performed on 12 cadavers. Localization of mental foramen according to teeth, distances of buccogingival sulcus-lip (BG-L), mental foramen-midline (MF-Midline), mental foramen - buccogingival sulcus (MF - BG), commissure - branching point (Cm - Br), branching point - vertical projection of branching point on lower lip (Br - LVP), vertical projection of branching point on lower lip - commissure (LVP - Cm), commissure - midline (Cm - midline), angles of mental (AM), angular (AA) and labial branches (AL) and branching patterns were recorded. Type 1 was mostly found as branching pattern in this study (45.8 %). A new branching pattern (type 9) was found on one cadaver. Mental foramen was mostly located at level of second premolar teeth. According to morphometric results of this study; supero- lateral to course of angular branch and infero-medial to course of mental branch of mental nerve on lower lip after exiting the mental foramen were described as safe zones during surgery for preserving mental nerve and its branches.

RESUMEN: El objetivo de este estudio fue revelar la morfometría del nervio mental o mentoniano para describir una zona segura y de esta manera, minimizar el daño de este nervio durante la tiroidectomía endoscópica transoral-abordaje vestibular (TOETVA). Este estudio se realizó en 12 cadáveres. Se realizó la localización del foramen mentoniano según los dientes, distancias surco gingival-labio (BG-L), foramen mentoniano-línea mediana (MF-Midline), foramen mentoniano-surco gingival (MF-BG), comisura-punto de ramificación (Cm-Br), punto de bifurcación - pro- yección vertical del punto de bifurcación en el labio inferior (Br - LVP), proyección vertical del punto de bifurcación en el labio inferior - comisura (LVP - Cm), comisura - línea mediana (Cm - línea mediana), ángulos del mentón (AM). Se registraron ramos angulares (AA) y labiales (AL) y patrones de ramificación. El tipo 1 se encontró principalmente como patrón de ramificación en el 45,8 %. Se describe un nuevo patrón de ramificación (tipo 9) encontrado en un cadáver. El foramen mentoniano se localizaba mayoritariamente a nivel de los segundos premolares. Según los resultados morfométricos, supero-lateral al curso de la rama angular e infero-medial al curso de la rama mentoniana del nervio mentoniano en el labio inferior, después de salir del foramen mentoniano, se describieron las zonas seguras, para la cirugía y preservación del nervio mentoniano y de sus ramos.

Clinical predictors of pulmonary functions, respiratory/peripheral muscle strength and exercise capacity at discharge in adults with burn injury.

PURPOSE: To identify clinical predictors of pulmonary functions, respiratory and peripheral muscle strength and functional exercise capacity in burn injury patients, and to compare these parameters with healthy subjects. METHODS: The study included 47 burn injury patients aged 20-49 years, and 47 age and gender-matched healthy subjects. The patients were evaluated on the day of discharge from hospital. Pulmonary functions and respiratory muscle strength were assessed with a spirometer (Cosmed Pony FX). Hand grip and pain were evaluated with a Jamar dynamometer and visual analog scale, respectively. The six-minute walk test (6-MWT) was performed to determine the functional exercise capacity of the participants. RESULTS: With the exception of FEV1/FVC, all the parameters of pulmonary functions test, respiratory and peripheral muscle strength and 6-MWT distances were lower in the burn injury patients than in the healthy subjects (p < 0.05). Significant predictors for these parameters were age, gender, height, body mass index, total burn surface area, burn injury type, the presence of trunk burn, hand burn, lower limb burn, inhalation injury, and intubation in the burn group (p < 0.05). CONCLUSIONS: Burn injury and the demographic characteristics of the patients are important determinants of clinical parameters. These results are clinically important as they can be of guidance in creating a personalized rehabilitation program. CLINICAL TRIAL REGISTRATION NUMBER: NCT03780218.Implications for rehabilitationBurn patients have impaired pulmonary functions and exercise capacity at discharge. Assessment of respiratory muscle strength should be added into clinical practice in adults with burn injury.Lung functions and exercise capacity should be evaluated in burn patients at discharge.It is important to monitor lung functions of burn patients after discharge.

Lower limb functional status and its determinants in moderate/major burns 3-6 months following injury: A two-center observational study.

INTRODUCTION: Severe complications which may cause impaired physical functionoften develops over time following severe burn to the lower extremities. The purpose of this study was to clarify the clinical determinants of lower limb functional status, functional mobility and exercise capacity in moderate/major burns 3-6 months following the injury. METHODS: The study included 42 patients, 12 with moderate injury and 30 with major injury, aged 19-59 years old. Lower Limb Functional Index was used to determine the lower limb functional status. Functional mobility and exercise capacity were evaluated with the Timed Up and Go test and the 6-min walk test, respectively. Scar quality and kinesiophobia were assessed with the Patient and Observer Scar Assessment Scale (POSAS) and the Tampa Scale for Kinesiophobia, respectively. Active range of motion (ROM) was measured with a universal goniometer. RESULTS: Significant and independent predictors of lower limb functional status, functional mobility and exercise capacity related to POSAS score, kinesiophobia level, gender, burn severity, the number of operations, the presence of burnsinvolving any of the lower limb joints, knee ROM limitations, limitation in any of the lower limb joint ROMs, comorbidities, and truncal burns (p < 0.05). CONCLUSIONS: Burn characteristics and clinical evaluations of patients are important determinants of the lower limb functional status, mobility and exercise capacity in burn patients. These predictors should be considered to improve physical functions related to the lower limb when creating a personalized rehabilitation program.

Does Preoperative Comprehensive Geriatric Assessment and Frailty Predict Postoperative Complications?

BACKGROUND: The influence of preoperative comprehensive geriatric assessment and frailty on postoperative morbidity, mortality, delirium were examined. METHODS: A total of 108 patients were evaluated. The Katz Index of Independence in Activities of Daily Living (ADL), the Lawton Brody Instrumental Activities of Daily Living Scale (IADL), the Mini-Nutrition Assessment test (MNA), the Mini-Mental State Examination (MMSE), Yesavage Geriatric Depression Scale (GDS) were performed. Fried Criteria were used to assess physical frailty. We used the Physiological and Operative Severity Scores for the Enumeration of Mortality and Morbidity score (POSSUM), the American Society of Anesthesiologists Score (ASA), and the Charlson Comorbidity Index (CCI) to determine the risk of postoperative morbidity and mortality. Assessment Test for Delirium (4AT) was applied for detection of delirium. RESULTS: The median age was 71 years (min-max: 65-84). IADL (p = 0.032), MNA (p = 0.01), MMSE scores (p = 0.026) were found to be significantly lower in patients with morbidity. POSSUM physiology score (p = 0.005), operative score (p = 0.015) and CCI (p = 0.029) were significantly higher in the patients with morbidity. Patients developed morbidity were found to be more frail (p < 0.001). The patients with delirium were found to have lower IADL (p = 0.049) and MMSE scores (p = 0.004), higher POSSUM physiology score (p = 0.005) and all of them were frail. It was found that frailty (OR = 23.695 95% CI: 6.912-81.231 p < 0.001), POSSUM operative score (OR:1.118 95% CI: 1.021-1.224 p = 0.016) and preoperative systolic blood pressure (OR:0.937%95 CI: 0.879-0.999 p = 0.048) were independently related factors for postoperative morbidity. CONCLUSION: In our study, CGA and frailty in preoperative period were found to be indicators for postoperative morbidity and delirium.

Fall of another myth for colon cancer: Duration of symptoms does not differ between right- or left-sided colon cancers.

BACKGROUND/AIMS: Patients with colorectal cancer continue to present with relatively advanced tumors that are associated with poor oncological outcomes. The aim of the present study was to assess the association between localization, symptom duration, and tumor stage. MATERIALS AND METHODS: A prospective, multicenter cohort study was conducted on patients newly diagnosed with a histologically proven colorectal adenocarcinoma. Standardized questionnaire-interviews were performed. Data were collected on principal presenting symptoms, duration of symptoms (time to first presentation to a doctor and time to diagnosis) and treatment, diagnostic procedures, tumor site, and stage of the tumor (tumor, node, and metastasis (TNM)). RESULTS: A total of 1795 patients with colorectal cancer were interviewed (mean age: 60.76±13.50 years, male patients: 1057, patients aged >50 years: 1444, colon/rectal cancer: 899/850, right side/left side: 383/1250, stage 0-1-2/stage 3-4: 746/923). No statistically significant correlations were found between duration of symptoms and either tumor site or stage. Principal presenting symptoms were significantly associated with left colon cancer. Patients who had "anemia," "change in bowel habits," "anal pruritus or discharge," "weight loss," and "tumor in right colon" had a significantly longer symptom time. CONCLUSION: Symptom duration is not associated with localization, nor is the tumor stage. Diagnosis of colorectal cancer at an earlier stage may be best achieved by screening of the population.

MRI evaluation of anal and perianal diseases.

Anal and perianal region is a commonly affected area in the course of several inflammatory, infectious, and neoplastic diseases. Several imaging modalities may be used in imaging evaluation of this area and magnetic resonance imaging (MRI) emerges as the imaging modality of choice due to its superb soft tissue resolution. MRI is not only useful for initial detection of anal/perianal pathologies but also in the follow-up of these disorders. In this article, we aimed to illustrate MRI findings of several diseases affecting this area including perianal fistula as well as anal fissure, hypertrophic myopathy of internal anal sphincter, hidradenitis suppurativa, pilonidal sinus, rectovaginal/anovaginal fistula and anal canal carcinoma. We think that this article will serve to familiarize the imaging specialists to the MRI findings of these diseases.

The contribution of preoperative MRI to the surgical management of anal fistulas.

PURPOSE: Anal fistula is an abnormal tract or cavity between the anal canal and perianal skin. Surgical treatment of anal fistulas requires the identification of the course of the primary and secondary tracts and their relation with the sphincter musculature in order to appropriately manage them and drain any abscess. Physical examination alone is not as accurate as imaging modalities in detecting these features of the fistula, and recurrences are usually due to missed or inadequately managed infective components. Magnetic resonance imaging (MRI) is the preferred imaging modality for detecting anal fistulas, but which patient group should undergo preoperative MRI is a matter of debate. The aim of this study was to determine the contribution of MRI in the surgical management of anal fistulas. METHODS: Medical records of patients who underwent surgery for primary anal fistula and preoperative MRI in our University Hospitals from January 1, 2008 to April 15, 2018 were collected anonymously and retrospectively. Any discrepancies between operative findings and MRI reports were noted. Two study groups were formed as per the contribution of preoperative MRI: significant and nonsignificant contribution groups. The significant contribution group included patients with secondary (blind) tracts, horseshoe fistulas, or abscesses undiagnosed at physical examination and examination under anesthesia; those with the location of the internal orifice different from that identified by physical examination; or those with the grade of the fistula assessed to be more advanced after preoperative MRI. RESULTS: The total number of surgeries was 136. Mean patient age was 43±13 years. There were 106 males. In total, 47 patients suffered from recurrent fistulas. MRI contribution to clinical evaluation was significant in 33.8% of the patients. MRI more frequently provided significant information for complex fistulas than for simple fistulas. Significant preoperative MRI contribution was more frequent if the external opening was more than 2 cm away from the anal canal or when a horseshoe fistula was present. CONCLUSION: Our study is valuable in linking physical examination findings with preoperative MRI findings. The distance of the external opening from the anal canal was not studied in the literature; our findings support the use of MRI for fistulas with external opening located more than 2 cm from the anus. These fistulas also tend to be complex and have a higher grade. In recurrent cases, MRI contributes not only by establishing the fistula anatomy but also by identifying possible sphincter damage.

The Effect of Warm Water Intake on Bowel Movements in the Early Postoperative Stage of Patients Having Undergone Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

This study was aimed at determining the effect of oral administration of warm water during the postoperative initial stage on the time of first flatus in patients who had undergone laparoscopic cholecystectomy. In the literature, it is emphasized that warm water has favorable effects on intestinal movements such as "reliving gastrointestinal spasms and helping peristalsis return." This randomized controlled trial and experimental study was conducted in a university hospital between May and December 2011. In the study sample, we included a total of 60 patients; 30 were in the experimental group (drank warm water), while the other 30 composed the control group. Patients were randomized through a simple random sampling method. The experimental group was provided with 200 ml of warm water at 98.6°F (37°C) in the fourth postoperative hour and were made to drink it within 15 minutes. Patients received no oral intake other than warm water until the eighth postoperative hour. The oral feeding of both groups started in the eighth postoperative hour with fluids and soft food. They shifted to the normal diet as tolerated. In the analysis of the data and percentage numbers, chi-square test and Fisher's exact test, Student's t test, Mann-Whitney U test, Kruskal-Wallis variance, and correlation analysis were used. The results of the data were considered reliable and statistically significant when they were in the reliability interval of 95% and p < .05. No significant differences were found between the patients in the experimental and control groups in terms of demographic features, bowel habits, surgery durations, postoperative applications, nausea/vomiting conditions, and initial mobilization times (p > .05). Groups were homogeneously distributed. Flatus expulsion in the experimental group was 11 ± 4.2 hours and was determined to be 18.6 ± 6 hours for patients in the control group (p < .05); in contrast, no significant difference was detected in terms of the times of stool defecation (p > .05). It was determined that warm water intake in the fourth postoperative hour significantly decreased the first flatus expulsion period and had a favorable impact on intestinal movements.

The analgesic efficacy of intra-articular acetaminophen in an experimental model of carrageenan-induced arthritis.

BACKGROUND: Acetaminophen is one of the most common drugs used for the treatment of pain and fever. OBJECTIVES: To examine the effects of intra-articular (IA) acetaminophen on carrageenan-induced arthritic pain-related behaviour and spinal c-Fos expression in rats. METHODS: The present study was performed using 20 Sprague Dawley rats. Forty microlitres of IA 0.9% NaCl was injected in the control group, and 40 µL of IA carrageenan was injected in the carrageenan group. One hour after carrageenan injection, 400 µg of IA acetaminophen was injected in the IA acetaminophen group, and 400 µg of intraperitoneal (IP) acetaminophen was injected in the IP acetaminophen group. One day before injection, and 4 h and 8 h after injection, diameters of both knee joints, motility of the rat, paw loading and joint mobility were assessed. After the rats were euthanized, L3 and L4 spinal segments were excised for c-Fos assessment. RESULTS: IA acetaminophen decreased both the severity and distribution of c-Fos expression. IP acetaminophen decreased only the distribution of c-Fos expression. IA acetaminophen decreased knee diameter at 8 h. IA and IP acetaminophen increased rat motility and paw loading scores. Joint mobility scores of IP acetaminophen were similar to saline at 8 h. CONCLUSIONS: Results of the present study indicate an analgesic and/or possible anti-inflammatory effect of IA acetaminophen and provide further evidence on the efficacy of systemic acetaminophen injection in reducing arthritic pain.

The effect of problem-based learning with cooperative-learning strategies in surgery clerkships.

BACKGROUND: Cooperative learning is used often as part of the problem-based learning (PBL) process. But PBL does not demand that students work together until all individuals master the material or share the rewards for their work together. OBJECTIVE: A cooperative learning and assessment structure was introduced in a PBL course in 10-week surgery clerkship, and the difference was evaluated between this method and conventional PBL in an acute abdominal pain module. METHODS: An experimental design was used. RESULTS: No significant differences in achievement were found between the study and control group. Both the study and control group students who scored low on the pretest made the greatest gains at the end of the education. Students in the cooperative learning group felt that cooperation helped them learn, it was fun to study and expressed satisfaction, but they complained about the amount of time the groups had to work together, difficulties of group work, and noise during the sessions. CONCLUSIONS: This study evaluated the impact of a cooperative learning technique (student team learning [STL]) in PBL and found no differences. The study confirms that a relationship exists between allocated study time and achievement, and student's satisfaction about using this technique.

Self-regulated learning strategies used in surgical clerkship and the relationship with clinical achievement.

INTRODUCTION: Self-regulated learning indicates students' skills in controlling their own learning. Self-regulated learning, which a context-specific process, emphasizes autonomy and control. Students gain more autonomy with respect to learning in the clinical years. Examining the self-regulated learning skills of students in this period will provide important clues about the level at which students are ready to use these skills in real-life conditions. OBJECTIVES: The self-regulated learning strategies used by medical students in surgical clerkship were investigated in this study and their relation with clinical achievement was analyzed. METHODS: The study was conducted during the surgery clerkship of medical students. The participation rate was 94% (309 students). Motivated Strategies for Learning Questionnaire (MSLQ), a case-based examination, Objective Structured Clinical Examination (OSCE), and tutor evaluations for assessing achievement were used. The relationship between the Motivated Strategies for Learning Questionnaire scores of the students and clinical achievement was analyzed with multilinear regression analysis. RESULTS: The findings showed that students use self-regulated learning skills at medium levels during their surgery clerkship. A relationship between these skills and OSCE scores and tutor evaluations was determined. OSCE scores of the students were observed to increase in conjunction with increased self-efficacy levels. However, as students' beliefs regarding control over learning increased, OSCE scores decreased. No significant relationship was defined between self-regulated learning skills and case-based examination scores. CONCLUSIONS: We observed that a greater self-efficacy for learning resulted in higher OSCE scores. Conversely, students who believe that learning is a result of their own effort had lower OSCE scores.

Combined long-term steroid and immunosuppressive treatment regimen in granulomatous mastitis.

BACKGROUND: Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It is related to various etiological factors. The treatment of IGM is challenging as there is a lack of consensus in the literature and treatment options vary widely. Conservative treatment with antibiotics, glucocorticoids and immunosuppressive drugs, and surgery are used in the management of the disease. In this article we report our experience with IGM patients receiving immunosuppressive treatment. PATIENTS AND METHODS: The medical records of patients with IGM receiving systemic therapy at the Hacettepe University Hospital between October 2007 and May 2010 were reviewed. 15 cases of histopathologically proven IGM were identified. The data was examined for risk factors and success of treatment. RESULTS: 14 patients were given prednisolone together with azathioprine, and 1 patient who was pregnant at the time of diagnosis received only prednisolone (30 mg/day). 11 (73%) patients had a complete response to systemic therapy. 2 patients had a relapse, of whom 1 required surgical drainage and 1 was treated with a higher dose of glucocorticoids. CONCLUSION: Systemic therapy is a safe and effective treatment for IGM. The addition of azathioprine to glucocorticoid therapy permits quick tapering of the steroid doses and increases the treatment success.

Scoring systems in the diagnosis of acute appendicitis in the elderly.

BACKGROUND: Although special features of acute appendicitis in the elderly have been described in some studies, no studies evaluating the applicability of appendicitis scores exist in the literature. The aim of this study was to compare Alvarado and Lintula scores in patients older than 65 years of age. METHODS: Patients older than 65 years with appendicitis confirmed by pathology report were matched by year of admission with a group of patients admitted to the emergency department with non-specific abdominal pain. Alvarado and Lintula scores were calculated retrospectively from patient charts. RESULTS: Both scores were observed to operate well in distinguishing between abdominal pain due to appendicitis and non-specific abdominal pain. The Alvarado score was a better predictor compared to the Lintula score. Two parameters (absent, tingling or high-pitched bowel sounds and nausea) had similar prevalence in the control and appendicitis groups. We selected to recalculate the two scores with the exclusion of these two parameters. The two scores performed better but were more similar to each other after the modification. CONCLUSION: Both Alvarado and Lintula scores have a high sensitivity and specificity in the diagnosis of acute appendicitis in the geriatric age group. Their performance improves with exclusion of the two parameters "nausea" and "absent, tingling or high-pitched bowel sounds".

Resuscitation and monitoring in gastrointestinal bleeding.

INTRODUCTION: Gastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately. MATERIALS AND METHODS: Articles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards. RESULTS: Decisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. "Functional hemodynamic monitoring" requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding. CONCLUSIONS: Management of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

Simultaneous forequarter amputation and radical mastectomy for metastatic breast carcinoma in a male patient: a case report.

Although the majority of forequarter amputations are performed for high-grade bone and soft tissue sarcomas or extensive osteomyelitis of the upper extremity, this radical operation may also be indicated for the curative treatment of recurrent breast cancer and for the palliation of locally advanced breast cancer. We report a male patient with metastatic breast adenocarcinoma who underwent simultaneous mastectomy and forequarter amputation for the management of both his primary and metastatic disease.

A novel fuzzy-logic inference system for predicting trauma-related mortality: emphasis on the impact of response to resuscitation.

INTRODUCTION: Trauma scoring aims for quantification and uniform reporting of trauma-related outcomes. Despite significant advances in trauma scoring, the exact time period at which relevant calculations should be made is not clear. Considering the importance of response to resuscitation, calculation of trauma scores after a period of resuscitation can allow better discrimination of patients who will survive. METHODS: A fuzzy-logic inference system, which is completely based on expert opinion and uses Glasgow Coma Scale (GCS) and systolic blood pressure at arrival to emergency room (ER) and their response to resuscitation as inputs, was developed. Records of the last 150 trauma patients admitted to our surgical intensive care unit (ICU) were used for calculations related to Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma and Injury Severity Score, and A Severity Characterization of Trauma (ASCOT) systems. Calculation of trauma severity and predicted mortality was performed at different time intervals during resuscitation [at arrival to emergency room (ER), after 1 h of resuscitation, and at ICU admission]. The performance of conventional systems and fuzzy-logic system was compared. RESULTS: Mean ISS was 32.31 ± 14.01. All systems included showed acceptable discriminative power. Among the conventional systems calculated at emergency room admission, ISS was the best performing [receiver operating characteristics (ROC), 0.9033] and RTS was the worst (ROC, 0.8106). Their performances were improved by up to 13% by use of post-resuscitation physiologic variables. Fuzzy-logic inference system performed slightly better (ROC, 0.9247) then the conventional systems calculated at arrival to ER. CONCLUSIONS: Response to resuscitation has significant impact on trauma mortality and must be considered in trauma scoring and mortality prediction. Fuzzy logic provides important opportunities for design of better predictive systems.

Preputial skin can be used in all boys with burns requiring grafting.

BACKGROUND: In patients with extensive burns, all unburned areas can be used as donor sites. In male patients with small burns, preputial skin graft may be a good choice in order to avoid donor site problems. METHODS: We retrospectively reviewed 12 patients treated in our burn center from January 1997 to August 2007 with preputial skin grafting. RESULTS: In three patients, preputial skin was the only graft source. In nine patients, other donor sites were also used for split-thickness graft harvesting. In two patients, preputial skin graft was used for periareolar grafting where hyperpigmented healing was preferred. In the rest of the patients, preputial skin graft was used on various parts of the body. Overall success rate for preputial skin graft was 100%. There was no early donor site morbidity. CONCLUSION: Preputial skin is a full-thickness, highly elastic and easy-to-harvest graft that should be considered in all burned male children in whom grafting is needed.