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.

The role of HBV DNA and liver histopathology in HBsAg carriers.

BACKGROUND/AIMS: In this study, we evaluated the association among serum transaminase values, seropositivity of HBV DNA and liver histopathology of patients with positive HBsAg and HBe antibodies. METHODOLOGY: Thirty-five patients were placed in two groups according to their serum transaminase values. Patients with normal transaminase values were evaluated in the first group. The patients with above normal transaminase values were subjected in the second group. RESULTS: In the first group of patients with normal transaminase values, biopsy-proven moderate or severe chronic hepatitis was not observed. HBV DNA seropositivity was 53.3% in this group. Forty-five percent of the patients with above normal transaminase values had moderate chronic hepatitis and seropositivity for HBV DNA in this group was 55%. Our results supported the association between transaminase values and liver pathology, but no statistically significant association was shown between seropositivity of HBV DNA and liver pathology. CONCLUSION: There is much to be studied to understand the function of HBV DNA in the follow up of HBsAg carriers, and liver biopsy has to be used routinely in the follow up of asymptomatic carriers when they happen to have high transaminase values.

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.

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.

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.

Evaluation of trauma care in a developing country highlighted by a major aircraft accident.

The aim of this study was to evaluate the day-to-day trauma care in a developing country highlighted by a major accident. In this accident, early management was not carried out according to triage principles. Scene mortality and in-hospital mortality were 72% (n = 55) and 14% (n = 3), respectively. Overall mortality rate was 76%. Five survivors were minor wounded. Three laparotomies, one thoracotomy and three tube thoracostomies were performed in the acute phase. Skeletal injuries, mainly rib fractures (43.3%) and haemothorax (10.8%), were the most frequent pathologies seen. One liver laceration, one splenic rupture, one intraabdominal bleeding due to rupture of mesenteric vessels, two major cranial traumas and an abruptio placenta were the other pathologies. The missed injury rate in this accident was 16% (n = 6). It is concluded that the missed injuries in this incident reflect the inadequacy of trauma care in the rural area of the developing country.

Prospective, double-blind, comparative fast-tracking trial in an academic emergency department during a period of limited resources.

The aim of this study was to determine the effectiveness of 'fast-tracking' in an academic emergency department (ED) during a period of limited resources and space constraints. This was a prospective, double-blind, comparative clinical trial. Fast-tracking was applied every other day between 08.00 and 17.30 hours. Patients meeting fast-tracking criteria, which were determined as allergy, dyspepsia, hypertension, urinary tract infection, urolithiasis, gastroenteritis, upper airway infection, minor lacerations, and soft tissue injuries with no sign or symptom of life-threatening illness or acute abdomen, were treated by a designated fast-tracking team. In the alternate days fast-tracking was not done, and the patients having the same criteria were recorded and followed as the control group. ED length of stays were determined for each patient, and at time of discharge a questionnaire was applied to determine patient satisfaction. Follow-up was performed by telephone survey at the 5th day of discharge. The median length of stay was 36 minutes for the fast-tracked group compared with 63 minutes for the control group. The application of fast-tracking decreased ED length of stay and improved patient satisfaction in patients presenting with allergy, dyspepsia, upper airway infection, minor laceration, and soft tissue injury, but not in patients with gastroenteritis, urinary tract infection, hypertension, and urolithiasis. The rate of follow-up was 81% (n = 217), and there were no complications or hospitalizations to another hospital. It is concluded that fast-tracking is an applicable and useful system in an academic ED with limited resources, and decreases ED length of stay and improves patient satisfaction in a selected group of patients. Determination of fast tracking criteria must be individualized for each hospital according to resources. Additionally, fast-tracking seems to be safe when performed under strict criteria for patient selection.

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.

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.

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.

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.