A novel approach to distinguish complicated and non-complicated acute cholecystitis: Decision tree method.

It is difficult to differentiate between non-complicated acute cholecystitis (NCAC) and complicated acute cholecystitis (CAC) preoperatively, which are two separate pathologies with different management. The aim of this study was to create an algorithm that distinguishes between CAC and NCAC using the decision tree method, which includes simple examinations. In this retrospective study, the patients were divided into 2 groups: CAC (149 patients) and NCAC (885 patients). Parameters such as patient demographic data, American Society of Anesthesiologists (ASA) score, Tokyo grade, comorbidity findings, white blood cell (WBC) count, neutrophil/lymphocyte ratio, C-reactive protein (CRP) level, albumin level, CRP/albumin ratio (CAR), and gallbladder wall thickness (GBWT) were evaluated. In this algorithm, the CRP value became a very important parameter in the distinction between NCAC and CAC. Age was an important predictive factor in patients with CRP levels >57 mg/L, and the critical value for age was 42. After the age factor, the important parameters in the decision tree were WBC and GBWT. In patients with a CRP value of ≤57 mg/L, GBWT is decisive and the critical value is 4.85 mm. Age, neutrophil/lymphocyte ratio, and WBC count were among the other important factors after GBWT. Sex, ASA score, Tokyo grade, comorbidity, CAR, and albumin value did not have an effect on the distinction between NCAC and CAC. In statistical analysis, significant differences were found groups in terms of gender (34.8% vs 51.7% male), ASA score (P < .001), Tokyo grade (P < .001), comorbidity (P < .001), albumin (4 vs 3.4 g/dL), and CAR (2.4 vs 38.4). By means of this algorithm, which includes low-cost examinations, NCAC and CAC distinction can be made easily and quickly within limited possibilities. Preoperative prediction of pathologies that are difficult to manage, such as CAC, can minimize patient morbidity and mortality.

A model for acute kidney injury in severe burn patients.

INTRODUCTION: In patients with severe burns, morbidity and mortality are high. One factor related to poor prognosis is acute kidney injury. According to the AKIN criteria, acute kidney injury has 3 stages based on urine output, serum creatinine level, and renal replacement therapy. In this study, we aimed to create a decision tree for estimating risk of acute kidney injury in patients with severe burn injuries. METHODS: We retrospectively evaluated 437 adult patients with ≥20% total burn surface area injury who were treated at the Baskent University Ankara and Konya Burn Centers from January 2000 to March 2020. Patients who had high-voltage burn and previous history of kidney disease were excluded. Patient demographics, medical history, mechanism of injury, presence of inhalation injury, depth of burn, laboratory values, presence of oliguria, need for renal replacement therapy, central venous pressure, and prognosis were evaluated. These data were used in a "decision tree method" to create the Baskent University model to estimate risk of acute kidney injury in severe burn patients. RESULTS: Our model provided an accuracy of 71.09% for risk estimation. Of 172 patients, 78 (45%) had different degrees of acute kidney injury, with 26 of these (15.1%) receiving renal replacement therapy. Our model showed that total burn surface area was the most important factor for estimation of acute kidney injury occurrence. Other important factors included serum creatinine value, burn injury severity score, hemoglobin value, neutrophil-to-lymphocyte ratio, and platelet count. CONCLUSION: The Baskent University model for acute kidney injury may be helpful to determine risk of acute kidney injury in burn patients. This determination would allow appropriate treatment to be given to high-risk patients in the early period, reducing the incidence of acute kidney injury.

Fucoidan and Derived Oligo-Fucoses: Structural Features with Relevance in Competitive Inhibition of Gastrointestinal Norovirus Binding.

Norovirus infections belong to the most common causes of human gastroenteritis worldwide and epidemic outbreaks are responsible for hundreds of thousands of deaths annually. In humans, noroviruses are known to bind to gastrointestinal epithelia via recognition of blood-group active mucin-type O-glycans. Considering the involvement of l-α-fucose residues in these glycans, their high valency on epithelial surfaces far surpasses the low affinity, though specific interactions of monovalent milk oligosaccharides. Based on these findings, we attempted to identify polyfucoses (fucans) with the capacity to block binding of the currently most prevalent norovirus strain GII.4 (Sydney, 2012, JX459908) to human and animal gastrointestinal mucins. We provide evidence that inhibitory effects on capsid binding are exerted in a competitive manner by α-fucosyl residues on Fucus vesiculosus fucoidan, but also on the galacto-fucan from Undaria pinnatifida and their oligo-fucose processing products. Insight into novel structural aspects of fucoidan and derived oligosaccharides from low-mass Undaria pinnatifida were revealed by GCMS and MALDI mass spectrometry. In targeting noroviral spread attenuation, this study provides first steps towards a prophylactic food additive that is produced from algal species.

Oligosaccharides and Viral Infection: Human Milk Oligosaccharides versus Algal Fucan-Type Polysaccharides.

Norovirus infections belong to the most common causes of human gastroenteritis worldwide, and epidemic outbreaks are responsible for hundreds of thousands deaths annually. Strikingly, no antiviral treatment is available due to the difficulty in cultivating virions or in generating a vaccine, and due to the fact that their infection mechanisms are poorly understood. However, there is consent that noroviruses bind to histo-blood group antigens (HBGAs) on their way through the digestive tract. The HBGA profiles vary individually, making people more or less susceptible to different norovirus strains. In our current work, we tried to decipher the HBGA specificity of the most prevalent and clinically relevant norovirus GII.4 subfamily (Sydney 2012, JX459908) and its preferences for human milk oligosaccharides (HMOs) as potential anti-infectives. The structural evidence provided can explain at the molecular level why individuals with certain blood groups are at higher risk of infection, and how these infections may be prevented and treated by application of food additives. A central finding was that low-affinity binding of HMOs is surpassed by high-avidity binding of multivalent oligo- and polyfucoses as found in algal polysaccharides (fucoidans). Insight into structural details of fucoidans and their impact on noroviral-blocking efficiency is provided and discussed.

Beneficial effects of natural eggshell membrane versus placebo in exercise-induced joint pain, stiffness, and cartilage turnover in healthy, postmenopausal women.

PURPOSE: Despite its many health benefits, moderate exercise can induce joint discomfort when done infrequently or too intensely even in individuals with healthy joints. This study was designed to evaluate whether NEM® (natural eggshell membrane) would reduce exercise-induced cartilage turnover or alleviate joint pain or stiffness, either directly following exercise or 12 hours post exercise, versus placebo. PATIENTS AND METHODS: Sixty healthy, postmenopausal women were randomly assigned to receive either oral NEM 500 mg (n=30) or placebo (n=30) once daily for two consecutive weeks while performing an exercise regimen (50-100 steps per leg) on alternating days. The primary endpoint was any statistically significant reduction in exercise-induced cartilage turnover via the biomarker C-terminal cross-linked telopeptide of type-II collagen (CTX-II) versus placebo, evaluated at 1 and 2 weeks of treatment. Secondary endpoints were any reductions in either exercise-induced joint pain or stiffness versus placebo, evaluated daily via participant questionnaire. The clinical assessment was performed on the per protocol population. RESULTS: NEM produced a significant absolute treatment effect (TEabs) versus placebo for CTX-II after both 1 week (TEabs -17.2%, P=0.002) and 2 weeks of exercise (TEabs -9.9%, P=0.042). Immediate pain was not significantly different; however, rapid treatment responses were observed for immediate stiffness (Day 7) and recovery pain (Day 8) and recovery stiffness (Day 4). No serious adverse events occurred and the treatment was reported to be well tolerated by study participants. CONCLUSION: NEM rapidly improved recovery from exercise-induced joint pain (Day 8) and stiffness (Day 4) and reduced discomfort immediately following exercise (stiffness, Day 7). Moreover, a substantial chondroprotective effect was demonstrated via a decrease in the cartilage degradation biomarker CTX-II. Clinical Trial Registration number: NCT02751944.

Epidemiological and cost analysis of burn injuries admitted to the emergency department of a tertiary burn center.

BACKGROUND: Burn injury is an emergency medical condition that rapidly develops as a result of tissue exposure to electrical, chemical or thermal energy. Therefore, its treatment usually begins at the emergency department. In this study we aimed to perform an epidemiological analysis of burn injuries presenting to the emergency department of a tertiary burn center, and factors affecting the cost of their medical care. METHODS: Patients who presented to Baskent University Ankara Hospital Adult Emergency Department with burn injuries between January 2012 and December 2014 were studied for age, sex, time of admission, type of burn injury, clinical prognosis, mortality rate, percent burn area, and total cost of care. A total of 264 patients were enrolled. Chi square test was used for the comparison of categorical variables. Non-parametric tests were used for the comparison of continuous variables. RESULTS: This study included 179 (67.8 %) women and 85 (32.2 %) men. The most common types of burn injuries were hot water burns and scalding. Eleven point seven percent of the patients sustained burn injuries in occupational accidents. 95.1 % of the patients were discharged from the emergency and 4.5 % of them were hospitalized. Only 1 (0.4 %) patient died. There was no significant difference between patient outcomes (discharge vs. hospital admission) with respect to the cost of care (p = 0.846) No significant difference was found between the cost of care of surgical and non-surgical management of burn injuries (p = 0.206). No significant difference was found between the costs of care of different types of burn injuries (p = 0.053). There was a significant difference between burn degrees with respect to the cost of care (p = 0.038). A significant difference was found between the costs of care of patients with a percent burn area of less than 10 % and those with a percent burn area of more than 10 % (p < 0.001), indicating that as percent burn area increased, a proportional increase occurred in the cost of care. CONCLUSIONS: Burn degree and percent burn area were the main determinants of the cost of care of burn injuries. In conclusion, burn injuries are preventable by taking occupational measures and raising public awareness about domestic accidents.

Effect of Topical Platelet-Rich Plasma on Burn Healing After Partial-Thickness Burn Injury.

BACKGROUND To investigate the effects of platelet-rich plasma on tissue maturation and burn healing in an experimental partial-thickness burn injury model. MATERIAL AND METHODS Thirty Wistar albino rats were divided into 3 groups of 10 rats each. Group 1 (platelet-rich plasma group) was exposed to burn injury and topical platelet-rich plasma was applied. Group 2 (control group) was exposed to burn injury only. Group 3 (blood donor group) was used as blood donors for platelet-rich plasma. The rats were killed on the seventh day after burn injury. Tissue hydroxyproline levels were measured and histopathologic changes were examined. RESULTS Hydroxyproline levels were significantly higher in the platelet-rich plasma group than in the control group (P=.03). Histopathologically, there was significantly less inflammatory cell infiltration (P=.005) and there were no statistically significant differences between groups in fibroblast development, collagen production, vessel proliferations, or epithelization. CONCLUSIONS Platelet-rich plasma seems to partially improve burn healing in this experimental burn injury model. As an initial conclusion, it appears that platelet-rich plasma can be used in humans, although further studies should be performed with this type of treatment.

Surgical interventions for late complications of arteriovenous fistulas.

Our aim was to determine the most effective surgical treatment for arteriovenous fistula (AVF) complications after all other methods of salvage have failed. We evaluated 110 patients for 139 complications that occurred after the initial AVF placement and for whom surgical intervention was the last hope for retaining fistula access. Vascular steal syndrome and venous hypertension were the most common complications seen in our patients. The anastomoses of 17 of the vascular steal syndrome cases were narrowed either by stitches or by a polytetrafluoroethylene graft. The second most performed revision surgery was excision of the aneurysm and repair with primary suturing, followed by excision of the aneurysm and interposition grafting. Successful surgical outcomes were achieved in 111 of 139 procedures after revision surgery without constructing a new AVF. AVF salvage surgery is of paramount importance in order to increase the patency rate, which prolongs survival and increases the patient's quality of life.

A prospective clinical study of flow-mediated dilatation in burn injury.

The authors investigated endothelial function using flow-mediated dilatation (FMD) in burn patients. This study was done in burn patients with specific criteria on admission. Blood lipid profile at 1st day, high-sensitivity C-reactive protein, and FMD were assessed at 1st and 7th days, as well as at 1st and 3rd months. The highest values of high-sensitivity C-reactive protein were detected on the 7th day, which were significantly higher than those at 1st and 3rd months. The lowest value of FMD was observed on the 7th day. FMD values were higher during the 1st month compared with the 7th day. The highest value of FMD was detected in the 3rd month. It was found that FMD values measured at 7th day and 1st month were significantly lower in patients with a burn percentage of 40 or greater. Our results suggest that inflammation is more prominent on 7th day following burn. The decrease in FMD values on 7th day after injury can be attributed to endothelial damage. The increase in FMD on 3rd month after burn is attributable to effective burn treatment and gradual decrease of inflammatory mediators. The data from this study suggest that there is endothelial dysfunction and low-grade inflammation in burn patients. This condition is more prominent in patients with a burn ratio greater than 40%. Burn patients more frequently have impaired FMD, which may be indicative of arterial endothelial dysfunction and a marker for increased atherosclerosis.

Assessment of the effectiveness of silver-coated dressing, chlorhexidine acetate (0.5%), citric acid (3%), and silver sulfadiazine (1%) for topical antibacterial effects against the multi-drug resistant Pseudomonas aeruginosa infecting full-skin thickness burn wounds on rats.

The aim of this study was to compare the effects of four different topical antimicrobial dressings on a multi-drug resistant Pseudomonas aeruginosa contaminated full-thickness burn wound rat model. A total of 40 adult male Wistar albino rats were used. The control group (group 1), silver sulfadiazine (1%) group 2, chlorhexidine acetate (0.5%) group 3, citric acid (3%) group 4, and silver-coated dressing group 5 were compared to assess the antibacterial effects of a daily application to a 30% full-skin thickness burn wound seeded 10 minutes earlier with 10(8) CFU (colony forming unit)/0.5 mL of a multi-drug resistant Pseudomonas aeruginosa strain. Five groups (1 control group and 4 treatment groups) were compared. The administration of third-degree burns to all rats was confirmed based on histopathologic data. The tissue cultures from groups 2 and 5 exhibited significant differences compared to those of the other 3 groups, whereas no significant differences were observed between groups 1, 3, and 4. The effectiveness of the treatments was as follows: 1% silver sulfadiazine > silver-coated dressing > 3% citric acid > 0.5% chlorhexidine acetate > control group. Our results supported the efficacy of topical therapy by silver sulfadiazine and silver-coated dressing on infections caused by multi-drug resistant Pseudomonas spp.

Effect of static magnetic field on experimental dermal wound strength.

CONTEXT: An animal model. AIM: We sought to evaluate the effect of static magnetic fields on cutaneous wound healing. MATERIALS AND METHODS: Male Wistar rats were used. Wounds were created on the backs of all rats. Forty of these animals (M group) had NeFeB magnets placed in contact with the incisions, either parallel (Pa) and perpendicular (Pr) to the incision. The other 40 animals (sham [S] group) had nonmagnetized NeFeB bars placed in the same directions as the implanted animals. Half of the animals in each group were killed and assessed for healing on postoperative day 7 and the other half on postoperative day 14. The following assessments were done: gross healing, mechanical strength, and histopathology. STATISTICAL ANALYSIS USED: Intergroup differences were compared by using the Mann-Whitney U or t test. Values for P less than 0.05 were accepted as significant. RESULTS AND CONCLUSIONS: There were no differences between the magnetic and sham animals with respect to gross healing parameters. The mechanical strength was different between groups. On postoperative day 14, the MPr14 had significantly higher scores than the other groups. When static, high-power, magnetic fields are placed perpendicular to the wound, increased wound healing occurs in the skin of the experimental model.

Burns or phytophotodermatitis, abuse or neglect: confusing aspects of skin lesions caused by the superstitious use of fig leaves.

As a superstition, homemade decoctions are believed to be beneficial for several diseases. This kind of medical therapy, however, can lead to serious adverse effects. In this report, we present three cases from a single family. Each of the family members developed phytophotodermatitis after the application of a fig leaf decoction. The most severe effect was in the case of a 13-year-old boy who had been bathed with the fig leaf decoction; the two other cases were the parents who prepared and applied the medicine to their child's skin to heal the boy's congenital mental-motor retardation. Silver sulfadiazine was used for wound care. The mother was discharged 6 days after admission, the father, after 8 days, and the boy, after 14 days. Burnlike wounds in all three cases healed completely.

Use of telemedicine and telephone consultation in decision-making and follow-up of burn patients: Initial experience from two burn units.

OBJECTIVE: This study investigated the use of telemedicine in decision-making and follow-up of burn patients. METHODS: The Konya Burn Unit was established in July 2003, and up to December 2009, 187 patients were admitted to this unit, all of them were consulted-via audiovisual transmission of data (telemedicine)-to the same burn surgeon at the Ankara Burn Referral Center of our hospital network. Three basic systems are currently used: live interactive video, store-and-forward images, and telephone. The demographic data and burn criteria of the patients were investigated. Changes in the number of televisits and patient management were analyzed. RESULTS: During the 66-month timeframe, 525 televisits were performed on 187 patients. There were 126 males (67.4%) and 61 females (32.6%). The mean total burn surface area (percentage of total burn surface area burned) was 23.3 ± 17.8% (range, 3-95%). Nine of the 187 patients (4.8%) died owing to multiorgan failure and sepsis. As a result of these televisits, 21 patients (11.2%) were transferred to our referral center. The number of dead and transferred patients decreased during the study. CONCLUSIONS: Telemedicine is appropriate and cost-effective for treatment and follow-up of patients in burn units with personnel with limited experience.

Steroid-resistant acute rejections after liver transplant.

OBJECTIVES: Liver transplant is the definitive treatment for the end-stage liver disease. Although effective immunosuppressants are available, steroid-resistant acute rejection can be encountered. MATERIALS AND METHODS: Between September 2001 and April 2010, 285 adult and pediatric liver transplants were done on 279 patients from deceased donors and living-related donors at our center. All patients received tacrolimus-based immunosuppressive therapy. Steroids were tapered in 3 months. Liver biopsy was done to confirm acute rejection after vascular or biliary complications had been excluded. High-dose steroids were administered for acute rejections. If there was no response to steroids, acute rejection was defined as steroid-resistant acute rejection. After confirming steroid-resistant acute rejection by a second biopsy, antithymocyte globulin was given to patients until liver functions return to normal level with ganciclovir prophylaxis. RESULTS: Acute rejection was detected in 87 liver transplants (30.5%). Steroid-resistant acute rejections were detected in 12 of 87 patients (7 male, 5 female; 8 pediatric, 4 adult patients; mean age, 16.08 +/- 12.1 years) (13.7%). Mean time from transplant to steroid-resistant acute rejection was 73.58 +/- 59.24 days (range, 20-181 days). The predominant cause of liver disease before liver transplant in patients who had steroid-resistant acute rejection was fulminant hepatic failure. Steroid-resistant acute rejection therapy was successful in 10 of 12 patients (83.3%). Two patients did not respond to therapy; therefore, they advanced to chronic rejection. Adverse effects due to cytokine release were the most frequently encountered reactions in the early period of antithymocyte globulin treatment. The mean follow-ups after steroid-resistant acute rejection treatment were 38.2 +/- 26 months (range, 2-85 months). We did not encounter any serious reaction, serious infection, or long-term adverse effect after antithymocyte globulin treatment. CONCLUSIONS: According to our experience, antithymocyte globulin can be considered as a good therapeutic option in steroid-resistant acute rejection with acceptable adverse effects.

Treatment approaches for spontaneous retroperitoneal bleeding.

In this study, we investigated critical issues in the diagnosis and treatment of spontaneous retroperitoneal bleeding. The medical records of 16 patients who were admitted to the emergency department and were diagnosed as having spontaneous retroperitoneal bleeding were reviewed retrospectively. Retroperitoneal bleeding was diagnosed by intravenous contrast-enhanced computed tomography in 8 men and 8 women (median age, 70.5 years; mean hemoglobin level, 7.4 +/- 1.3 mg/dl). Thirteen patients (81%) received conservative treatment. Bleeding was controlled by therapeutic angiographic intervention in two patients (12%) and by surgery in one patient (6%). Two patients (12%) died. Clinicians should suspect retroperitoneal bleeding in anemic patients who are admitted to an emergency department. If active bleeding is detected, interventional radiologic methods should be used as the initial treatment, and surgery can be performed if conservative and interventional radiologic methods fail.

Food supplementation with an olive (Olea europaea L.) leaf extract reduces blood pressure in borderline hypertensive monozygotic twins.

Hypertension is a harmful disease factor that develops unnoticed over time. The treatment of hypertension is aimed at an early diagnosis followed by adequate lifestyle changes rather than pharmacological treatment. The olive leaf extract EFLA943, having antihypertensive actions in rats, was tested as a food supplement in an open study including 40 borderline hypertensive monozygotic twins. Twins of each pair were assigned to different groups receiving 500 or 1000 mg/day EFLA943 for 8 weeks, or advice on a favourable lifestyle. Body weight, heart rate, blood pressure, glucose and lipids were measured fortnightly. Blood pressure changed significantly within pairs, depending on the dose, with mean systolic differences of < or =6 mmHg (500 mg vs control) and < or =13 mmHg (1000 vs 500 mg), and diastolic differences of < or =5 mmHg. After 8 weeks, mean blood pressure remained unchanged from baseline in controls (systolic/diastolic: 133 +/- 5/77 +/- 6 vs 135 +/- 11/80 +/- 7 mmHg) and the low-dose group (136 +/- 7/77 +/- 7 vs 133 +/- 10/76 +/- 7), but had significantly decreased for the high dose group (137 +/- 10/80 +/- 10 vs 126 +/- 9/76 +/- 6). Cholesterol levels decreased for all treatments with significant dose-dependent within-pair differences for LDL-cholesterol. None of the other parameters showed significant changes or consistent trends. Concluding, the study confirmed the antihypertensive and cholesterol-lowering action of EFLA943 in humans.

A novel technique for hepatic arterial reconstruction in living-donor liver transplant.

OBJECTIVES: Arterial reconstruction in patients undergoing living-donor liver transplant is technically difficult because of the small diameter of the vessels in the partial liver graft. In this study, we present our technique for hepatic arterial reconstruction. METHODS: Since December 2005, we have performed 54 living-donor liver transplants, which are analyzed retrospectively in this report. In our technique now used at our institution, native and graft hepatic arteries are spatulated from both the anterior and posterior walls to provide a wide anastomosis. Computed tomographic angiography is used to evaluate the vascular anatomy and to measure the diameter of the graft hepatic arteries. RESULTS: Mean follow-up was 7.2 +/- 5.5 months (range, 1-17 months). Nine of the 54 recipients died within 4 months of the surgery. At the time of this writing, the remaining 45 recipients (84%) are alive and demonstrating good graft function. In 2 recipients (3.7%) in this series, hepatic artery thromboses developed, which were treated with an interventional radiologic technique. CONCLUSIONS: Our arterial reconstruction technique has enabled reconstruction of smaller arteries and arteries of various diameters without an operating microscope. The rate of complications in our patients is similar to that reported in similar individuals.

Renal autotransplantation for complex renal arterial disease: a case report.

A renal artery aneurysm in a stenotic renal artery is a rare clinical entity with an incidence of 0.015% to 1% in patients with renovascular hypertension. Interventional stent placement is the first line of treatment for simple aneurysms of the proximal renal artery. However, renal autotransplantation has been used as an alternative treatment for complex lesions and for lesions originating from the distal renal artery. We present a patient with a renal artery aneurysm, renal artery stenosis of the segmental branches of the left kidney, and occlusion of the right renal artery. The surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the 2 renal artery branches, and renal heterotopic autotransplantation. We conclude that renal autotransplantation is a safe and effective surgical procedure for patients with complex renal arterial disease.