Long-term sustainability of zero central-line associated bloodstream infections is possible with high compliance with care bundle elements.

Central-line-associated bloodstream infection (CLABSI) is one of the most important problems in intensive care units (ICUs) worldwide. A bundle of CLABSI care measures was introduced at a 13-bed medical/surgical ICU in Kocaeli, Turkey in January 2010. Compliance rates with the bundle were measured at the beginning of the third quarter of 2010 until June 2013 and compared with CLABSI rates. During the post-intervention period, of 2196 ICU patients, 732 lines placed for 4366 line-days were monitored. Feedback to staff reinforced a culture of patient safety in the ICU. Infection rates remained zero for 38 months after the implementation. There was a strong negative correlation between bundle compliance rate and CLABSI rates. With the implementation of the central-line bundle of care, together with emphasis on high compliance with all its components and a culture of patient safety, it was possible to achieve and maintain a zero rate of CLABSI in this ICU.

Evaluation of sludge management alternatives in Istanbul metropolitan area.

The main concern of this paper was to predict the sludge quantities generated from 18 wastewater treatment plants, which were stated to be established in the "Istanbul Water Supply, Sewerage and Drainage, Sewage Treatment and Disposal Master Plan", 10 of which are in operation at present. Besides this, obtaining the required data to compare various treatment schemes was another goal of the study. Especially, the estimation of the sludge quantity in the case of enhanced primary sedimentation was of importance. Wastewater sludge management strategies were discussed in order to develop suggestions for Istanbul Metropolitan city. Within this context, the wastewater treatment facilities, mentioned in the Master Plan that had been completed by 2000, were evaluated in terms of sludge production rates, locations and technical and management aspects. Disposal alternatives of the wastewater treatment sludge were also evaluated in this study. Using of the dewatered sludge as a landfill cover material seems the best alternative usage. Up to the year of 2040, the requirement of cover material for landfills in Istanbul will be met by the dewatered sludge originated from wastewater treatment plants in the region.

Antibiotic stewardship programmes and the surgeon's role.

Inappropriate antibiotic use is a frequent occurrence, especially in surgical units. Among the unnecessary costs of such usage are unfavourable outcomes for patients and the emergence and spread of resistant bacteria. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. Such programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. In this paper, I discuss the impact of improper use of antibiotics and outline why I believe that antibiotic stewardship is likely to be the best way of dealing with it. Engagement of surgeons in antibiotic stewardship programmes is crucial to their success.

Neutropenic enterocolitis in patients without leukemia.

BACKGROUND: Neutropenic enterocolitis is a serious complication involving the bowel in patients with severe neutropenia. Most of the patients are undergoing chemotherapy for acute leukemia. METHODS: This is a report of three cases of nonleukemic neutropenic enterocolitis. In these cases neutropenia was caused by an analgesic (dipyrone), chemotherapy for multiple myeloma, and chemotherapy for lung carcinoma. Two patients were treated by surgery, one medically. RESULTS: The patient with multiple myeloma who was treated by exteriorization of the sigmoid colon died on the tenth postoperative day of multiple organ failure caused by sepsis. The other two patients survived. CONCLUSIONS: A review of the literature revealed 14 other patients without leukemia who had neutropenic enterocolitis. The cause, diagnosis, and possible treatment options of this entity are discussed.

A new approach in the treatment of hypotension in human septic shock by NG-monomethyl-L-arginine, an inhibitor of the nitric oxide synthetase.

NG-monomethyl-L-arginine (L-NMMA) is an inhibitor of the enzyme nitric-oxide-synthetase. Nitric oxide (NO), produced by endothelial and vascular cells regulates physiological vascular tone, blood pressure and tissue perfusion via guanylate-cyclase and cGMP. In an advanced stage of therapy resistant septic shock in response to inflammatory mediators, NO is overproduced. This leads to vasodilatation, a fall in systemic blood pressure and an attenuated vasoconstriction-response to sympathetic-stimuli. Two episodes of severe and prolonged hypotension in a patient with sepsis were successfully treated twice by bolus therapy of L-NMMA within 4 weeks. On both occasions blood pressure was reversed to normal and the continuous use of high doses of catecholamines were stopped. In contrast to the immediate response of blood pressure, heart rate and central venous pressure remained stable. Cardiac output dropped to 68% and PaO2 increased. These findings indicate that NO-synthetase-inhibitors may be of value in the therapy of human septic shock.

Prophylactic effect of albendazole in experimental peritoneal hydatidosis.

To determine the effectiveness of prophylactic short-term administration of albendazole in experimental peritoneal hydatidosis this substance was given at a dose of 15 mg/kg for 96 hours prior to scolex implantation. In contrast to the 81.8% of the controls, only 11.1% of the experimental animals developed intraperitoneal hydatidosis over a period of 18 weeks (p < 0.001). The newly defined cyst index was also decreased from 2.09 to 0.22 by the administration of albendazole (p < 0.005). It is concluded that albendazole, when given for 96 hours prior to any suspected intraperitoneal spillage of viable hydatid cyst contents could significantly reduce secondary peritoneal hydatidosis.

Penetration of fleroxacin into human lung, muscle, and fat tissue.

Fleroxacin is a new fluoroquinolone with established potent antimicrobial and pharmacokinetic properties, and the aim of this study was to determine its rate of penetration into human lung, muscle, and fat tissues. In a total of eight patients undergoing lung surgery, plasma and tissue concentrations of unmetabolized fleroxacin were determined. This was done in subgroups of two patients each, receiving either 6, 8, 12 or 24 hours prior to surgery one single oral dose of 400 mg fleroxacin. It was found that fleroxacin penetrates well into muscle and lung tissues, but not into fat tissue. The levels in muscle and lung were 1.1 to 4.7 times higher than the according plasma concentrations.

Randomized comparative trial of imipenem/cilastatin versus aminoglycoside plus amoxycillin plus clindamycin in the treatment of severe intra- and post-operative infections.

In a prospective, randomized, controlled study, clinical and bacteriological efficacy of imipenem/cilastatin (I/C) was compared with a standard combination of aminoglycoside + amoxycillin + clindamycin (C) in patients (pts) with severe intra- and postoperative infections. A total of 84 pts were randomly separated into two groups of 42 pts. Diagnoses were pneumonia n = 21 (14 in I/C group and 7 in C), peritonitis n = 45 (16 in I/C group and 29 in C), septicaemia n = 12 (9 in I/C group and 3 in C), and 7 other infections (3 in I/C group and 4 in C). Doses used were imipenem/cilastatin 1 g q 8 h and amoxycillin 2 g q 8 h plus clindamycin 0.6 g q 6 h, plus netilmicin according to serum concentrations. Success rates were 85.4% (n = 35: 34 cured and one improved) in the I/C group and 83.3% (n = 35: 30 cured and five improved) in the C group. Six pts in group I/C and 7 in group C failed to respond to treatment. One patient in the I/C group was not assessable. 62% of the bacterial isolates were eradicated in the I/C group and 55% in group C. 7% were suppressed in I/C and 5% in C. It is concluded that imipenem/cilastatin is an effective and well-tolerated alternative to antibiotic combinations in severe intra- and post-operative infections. It offers the advantages of fewer drug doses and less renunciation of serum drug concentration monitoring.

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.

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.

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.

[Honey-induced poisoning]. / Honigbedingte Intoxikationen.

Because of the increasing preference for natural products intoxications induced by consumption of honey will reappear, especially with products bought directly from the beekeeper. In the hospital of Trapezunt about 8 cases of intoxications induced by honey were reported per year. The courses observed appear to be identical to those already described by Xenophon 2400 years ago. Symptoms begin acutely but last rarely for more than 24 hours. Fatal cases are extremely rare. Most prominent symptoms are loss of consciousness, weakness, severe salivation, sweating, vomiting and diarrhea. Beside these symptoms circumoral paresthesias and bradyarrhythmia may occur. Intoxication is induced by certain diterpenes, so called gray-anotoxins, that appear in flowers of different species of rhododendron. Next to close surveillance only symptomatic therapy is generally necessary.

[Thoracopagus symmetricus. On the separation of Siamese twins in the 10th century A. D. by Byzantine physicians]. / Thoracopagus Symmetricus. Zur Trennung von siamesischen Zwillingen im 10. Jahrhundert n. Chr. durch byzantinische Arzte.

The byzantine author, Leon Diakonos, mentions in 974/975 A.D. a pair of "siamese twins", e.g., a thoracopagus symmetricus. He had seen them personally several times in Asia Minor when they were about 30 years old. This pair is possibly the same that was "successfully" surgically separated after the death of one of the twins in the second half of the 10th century in Constantinople. This operation is mentioned by two historiographs, Leon Grammatikos and Theodoros Daphnopates. Although the second twin survived the operation, he died three days later. In spite of its lethal outcome, the operation left a long-lasting impression on the historians of that time and was even mentioned 150 years later by Johannes Skylitzes. Furthermore, the manuscript of Skylitzes, now in the library of Madrid, contains a miniature illuminating this operation. This is likely to be the earliest written report of a separation of siamese twins illustrating the high standard of byzantine medicine of that time.

The effect of prophylactic mebendazole in experimental peritoneal hydatidosis.

The primary treatment of hydatid disease is surgical. The most important complication of the surgical treatment is secondary hydatidosis due to spillage of the cyst contents. Medical treatment, with mebendazole, has been used extensively. This study was undertaken to evaluate the prophylactic effect of mebendazole in experimental peritoneal hydatidosis. Mebendazole was given for 96 hours in a dose of 40 to 65 milligrams per kilogram per day before the inoculation of scolices intraperitoneally. This prophylactic therapy decreased the intraperitoneal formation of cysts significantly from 80 to 11 per cent (p less than 0.005). The preoperative administration is recommended to prevent secondary hydatidosis due to spillage of scolices during the operative intervention.

[Laparoscopic management of echinococcal cysts of the liver]. / Laparoskopische Behandlung der Echinokokkuszysten der Leber.

Even though echinococcal cysts have been cured by puncture and instillation of scolicidal medications, surgery is still the mainstay of the treatment of hydatid disease. The aim of the surgical treatment is the elimination of scolices, the removal of all viable parts of the cyst and the obliteration of the remaining cavity. This can be achieved by resective procedures, but also by a more conservative approach with drainage and obliteration of the cyst. The latter procedure can be done by open surgery or laparoscopically. The disadvantages of the laparoscopic approach are the increased danger of contamination of the abdominal cavity with scolices and difficulties to aspirate a highly viscous cyst content. Furthermore, cysts which are located deep in the parenchyma of the liver should not be approached laparoscopically because of the significant danger of hemorrhage. The advantage of the laparoscopic approach in selected cysts, i.e. those which are located superficially and having a liquid content, are a shorter hospital stay, lower incidence of wound infection and the ability of the surgeon to inspect the inside of the cyst more thoroughly and rule out daughter cysts and connections to the biliary tract. A review of the literature (n = 76) indicates that in most laparoscopically treated hydatid cysts of the liver a simple drainage (59%) or an unroofing (31%) is performed. The complication rate is 21%. Because there are no longterm observations after laparoscopic operations for hydatid disease the question of recurrence cannot yet be answered.

Effect of reuterin produced by Lactobacillus reuteri on the surface of sausages to inhibit the growth of Listeria monocytogenes and Salmonella spp.

Reuterin is a bacteriocin produced by some strains of Lactobacillus reuteri. The strain used in this study was isolated from raw milk from a dairy farm nearby Ankara. Beef sausage is a long years produced bratwurst style meat product in Turkey, as well as in some other countries in the Mediterranean region. Sausages are produced by raw meat; sometimes lactic starter cultures are added or spontaneous fermentation is employed. The production and storage conditions of the product promotes the growth of Listeria monocytogenes and Salmonella spp. Although nitrate is added as an antimicrobial substance against many pathogens, sometimes however nitrate application is not preventive enough on the surface because of the natural film around the sausages. Since most of the contaminations take place at post production steps, pathogenic growth is more effective on the surface of the sausages in refrigerated conditions. In this study, reuterin was applied to the surface of the sausages in order to prevent the growth of these two pathogens along with nitrate used as an additive in the product. Reuterin has inhibited the growth of L. monocytogenes considerably but not of Salmonella spp. on the surface of the sausages.

[Lung abscess: evolution of a complication over 45 years]. / Der Lungenabszess: Evolution einer Komplikation über 45 Jahre.

143 patients with lung abscesses were hospitalised at the Department of Surgery at University Hospital Zurich from 1946 to 1990. Analysing our patients in a retrospective study we concluded as follows: 1. Lung abscesses have nearly disappeared in our patients. 2. Lung abscesses can be cured without lethality. 3. Cancers of the lung causing abscesses were not seen any more since 1960. 4. A compromised immunological system appeared as a new pathogenetical factor since the beginning of the 1980ies.

Risk factors in perforated peptic ulcer disease: comparison of a new score system with the Mannheim Peritonitis Index.

OBJECTIVE: To construct a score that would accurately predict outcome for patients with perforated peptic ulcers. DESIGN: Retrospective study. SETTING: University Hospital. SUBJECTS: 173 patients who were operated on for perforated peptic duodenal ulcers over a 14 year period. MAIN OUTCOME MEASURES: Results of multivariate discriminant function analysis of derived set of clinical variables known to be associated with high mortality, and comparison with the Mannheim Peritonitis Index. RESULTS: Serious coexisting medical illness, acute renal failure, white cell count of more than 20 x 10(9)/l, and male sex were the most significant factors influencing mortality. The Hacettepe score for perforated peptic ulcer was established using these four variables. The sensitivity was 83%, the specificity 94%, and the overall predictive accuracy 93%. The corresponding figures for the Mannheim Peritonitis Index were 75%, 96%, and 94% respectively. CONCLUSION: The Hacettepe score is useful in predicting whether a patient will survive after perforation of a peptic duodenal ulcer.