AMAÇ: Hypericum perforatum (HP), Türkiye’de yýllardýr halk arasýnda yanýk yaralarýnýn tedavisinde kullanýlmaktadýr. Bu çalýþmada, deneysel haþlama tipi yanýklarda HP tedavisinin akut etkilerinin araþtýrýlmasý ve gümüþ sülfadiazin (GS) tedavisiyle karþýlaþtýrýlmasý amaçlandý.
GEREÇ VE YÖNTEM: Her grupta yedi adet olacak þekilde toplam beþ grupta 35 sýçan kullanýldý. Sýçanlarýn sýrt bölgesinde 4×4 cm’lik alan 100ºC suya 10 saniye maruz býrakýlarak haþlama tipi ikinci derece yanýk oluþturuldu. 50 cc serum fizyolojik (SF) ile tüm gruplara üç dakika boyunca irrigasyon saðlandý. Grup 1 (kontrol grubu) herhangi bir tedavi uygulanmadý. Grup 2 (yanýk kontrol grubu) sadece irrigasyon, Grup 3 [topikal gümüþ sülfadiazin (GS)] GS günde iki kez, Grup 4 (topikal HP grubu) HP günde dört kez (altý saatte bir), Grup 5 (aracý ile –jel- tedavi) HP hazýrlanmasýnda kullanýlan diðer topikal materyal günde dört kez (altý saatte bir) uygulandý. Dördüncü, sekizinci ve yirmi dördüncü saatlerde sýçan sýrt derisinden kare biçiminde 1x1 cm boyutlarýnda insizyonel biyopsiler alýndý. Derideki yara yeri iyileþmesi bulgularý histopatolojik olarak deðerlendirildi.
BULGULAR: Hypericum perforatum grubunun epidermis kalýnlýðýnýn ve damar sayýsýnýn diðer gruplara göre anlamlý oranda (p<0.05) daha fazla olduðu bu parametreler açýsýndan kontrol grubuna en yakýn grup olduðu ve saatler içerisinde de bu sayýlarýn farklýlýk göstermediði saptandý (p>0.05). Tüm gruplara göre HP grubunda dejenere kýl kökü sayýsý anlamlý oranda daha azdý (p<0.05) ve 24. saatlerde toplam kýl kökü sayýsýnda anlamlý oranda artýþýn olduðu (p<0.05) ve bu sayýnýn kontrol grubuyla farklýlýk göstermediði (p>0.05) saptandý.
TARTIÞMA: Deneysel haþlama tipi ikinci derece yanýk modelinde HP’nin ilk 24 saatte günde dört defa uygulanmasý net bir þekilde yanýk yara iyileþmesinde etkilidir ve GS tedavisinden ciddi anlamda üstündür.

BACKGROUND: Hypericum perforatum (HP) (St. John’s Wort-Kantaron) has been used widely for the treatment of burn injuries for many years in traditional Turkish medicine. The aim of study was to investigate HP treatment in experimental thermal burns and compare it with silver sulfadiazine (SS) treatment.
METHODS: Thirty-five rats were randomly assigned to one of the five groups, 7 rats in each. A second-degree thermal burn was created on the dorsal sites of rats by exposing an area of 4×4 cm to 100 °C boiled water for 10 seconds. All groups were provided with irrigation for three (3) minutes with 50 cc saline solution (SS). Group 1 (Control Group) was not administered any treatment. Group 2 (Burn Control Group) was administered only irrigation, Group 3 (topical silver sulfadiazine [SS]) was administered SS twice a day, Group 4 (the Topical HP Group) was administered HP four times a day (every six hours), Group 5 (treatment with agent -gel-) was administeredother topical material used for the preparation of HP four times a day (every six hours). Wound site healing on the skin was histopathologically evaluated.
RESULTS: It was found that collagen discoloration of the HP treatment group was localized in the lower part of the epidermal layer and did not go up to the depth of dermis compared to the other groups, and epidermis, hair follicles and sebaceous glands remained protected compared to the groups administered burn, gel and SS in every hour of the experiment and it was the group closest to the control group structurally. It was determined that the epidermal thickness and the number of vessels of the HP Group were significantly higher compared to the other groups (p<0.05), which was the group closest to the control group in terms of these parameters and these numbers did not show any difference within hours (p>0.05). The number of degenerated hair follicles in the HP Group was significantly less than the other groups (p <0.05), and it was determined that the total number of hair follicles significantly increased in the twenty-fourth (p<0.05) and this number did not differ by the control group (p>0.05).
CONCLUSION: Administration of HP four times a day within the first 24 hours is clearly effective in wound healing in the experimental thermal second degree burn modality and is significantly superior to SS treatment.

AMAÇ: Suda mayýn patlamasýnýn karakteristik özellikleri havada patlamalardan farklý olup suyun derinliðine göre deðiþmektedir. Sýð sularda oluþan mayýn patlamalarýnýn neden olduðu ekstremite yaralanmalarýnýn karakteristik özellikleri ve mekanizmalarýný araþtýrmak önem taþýmaktadýr.
GEREÇ VE YÖNTEM: Toplam 90 Yeni Zelanda tavþaný dört gruba randomize edilip farklý derinliklerdeki suya býrakýlmýþlardýr (kara grubu, uyluk kemiðinin yarýsý derinlikteki su, Grup 1; ksifoit çýkýntýya kadar derin su Grup 2 ve kontrol grubu). Mayýnlarý andýran elektronik patlatýcýlar tavþanlarýn arka patileri altýna yerleþtirildi. Patlama gerçekleþtirildikten sonra tavþanlar morfolojik incelemeye tabi tutuldu.
BULGULAR: Karada mayýnlarýn patlatýlmasýndan sonra tavþanlarýn bacaklarýnýn alt üçte biri hemen hemen yok olmuþtu. Sýð sulardaki patlatmalar sonrasý tavþanlarýn yalnýzca ayaklarý ve ayak bilekleri tahrip olmuþtu. Karadakilere göre sýð sulardakilerin iskeleti, arterleri ve siyatik sinirleri daha ciddi derecede yaralanmýþtý.
TARTIÞMA: Sýð sulardaki mayýn patlamalarý, karadaki patlamalara göre yumuþak dokuya daha az zarar vermiþtir. Ancak, basýnç dalgasý daha yoðun biçimde iletildiði ve iskelete daha güçlü paramparça edici etki gösterdiði için sýð sulardaki patlamalarda iskelet daha ciddi derecede yaralanmýþtý. Ayrýca ekstremite yaralanmalarýnda ekstremite yaralanmalarýnýn karakteristik özellikleri suyun derinliðine göre deðiþmiþtir.

BACKGROUND: The characteristics of explosion in water are different from those in air and vary in different water depths. It is important to investigate the characteristics and mechanisms of extremity injuries caused by mine blasts in shoals.
METHODS: A total of ninety New Zealand rabbits were randomly divided into four groups put in different depths of water (land group, midpoint of the thigh in the shoal 1 group, the xiphoid process in the shoal 2 group, and control group). Electric detonators simulating mines were placed under the rabbits’ right hindpaw. After detonation, the animals were subjected to morphological examination.
RESULTS: The lower third of the calf was almost completely destroyed by the mine blast on land, and only the rabbits’ feet and ankles were destroyed in shoals. The skeleton, artery and sciatic nerve were injured more seriously in shoals than those on land.
CONCLUSION: Mine blasts in shoals caused less disruption of the soft tissue than those on land. However, the skeleton was more seriously damaged in shoals since the pressure wave was transmitted with greater intensity and had a stronger shattering effect on the skeleton. Furthermore, the characteristics of extremity injuries varied according to water depths.

AMAÇ: Micropower impulse radar (MIR) teknolojisi ile çalýþan Pneumoscan cihazýnýn acil serviste pnömotoraks (PTX) tanýsý koyabilmedeki etkinliðini deðerlendirmeyi amaçladýk.
GEREÇ VE YÖNTEM: Pnömotoraks þüphesi bulunan ve toraks bilgisayarlý tomografisi (BT) endikasyonu olan hastalar çalýþmaya dahil edildi. Toraks tomografisindeki bulgular ile Pneumoscan cihazýnýn sonuçlarý karþýlaþtýrýldý. Katagorik deðiþkenlerin kýyaslanmasýnda ki-kare ve Fisher kesin testi kullanýldý.
BULGULAR: Çalýþma grubunu oluþturan 115 hastanýn toplam 12’sinde BT ile PTX tespit edildi. Pneumoscan’da 10 doðru pozitif sonuç, 36 doðru negatif sonuç, 67 yanlýþ pozitif sonuç, iki yanlýþ negatif sonuç vardý. Pneumoscan ile toraks BT’nin pnömotoraksý tespit edebilirliði arasýnda istatistiksel olarak anlamlý bir fark bulunmamýþtýr (p=0.33). Cihazýn pnömotoraksý tespit etmedeki sensitivitesi %83.3, spesifitesi %35.0 olarak bulundu. Göðüs tomografisinde görülen pnömotoraksýn boyutu ile cihazýmýzýn pnömotoraksý belirlemesi arasýnda anlamlý bir farklýlýk bulunamamýþtýr (p=0.470). Bilgisayarlý tomografide PTX’lerin sað ya da sol hemitoraksta olmasý ile cihazýn pnömotoraksý tespit etmesi arasýnda anlamlý bir farklýlýk bulunamamýþtýr (p=1.00). Pneumoscan’ýn doðru pozitif olarak tespit ettiði 10 hastanýn, tomografide ölçülen göðüs duvar kalýnlýðý ortalama 50.3 mm iken, yanlýþ negatif iki hastanýn göðüs duvar kalýnlýðý ise 56.5 mm olarak bulunmuþtur. Ancak göðüs duvar kalýnlýðý ile cihazýn taný koymasý arasýndaki iliþki istatistiksel olarak anlamlý deðildi (p=0.766). Pneumoscan’ýn yanlýþ pozitif olarak PTX var dediði 67 olgunun %46.3’ünde (n=31) BT’de bronþiektazi, konsolidasyon, sývý ve kitle gibi PTX dýþý bulgularý vardý. Tomografide ek bulgu olup olmamasý ile cihazýn pnömotoraks tespit edip etmesi arasýnda anlamlý bir farklýlýk bulunamamýþtýr (p=0.472).
TARTIÞMA: Çalýþmamýzla pnömotoraksý olan hastalarý ayýrt etme konusunda etkin olan Pneumoscan cihazýnýn acil serviste kullanýmý, yüksek yanlýþ pozitiflik oranýndan dolayý tartýþmalý hale gelmiþtir. Yanlýþ pozitif taný oranýndaki bu yükseklik bazý hastalara gereksiz chest tube takma giriþimine neden olabilir. Ayrýca pnömotoraksýn büyüklüðünü gösteremeyen Pneumoscan cihazý, geleneksel tanýsal görüntüleme yöntemlerinin aksine verilecek tedaviyi ve prognozu belirlemede yardýmcý olamamaktadýr. Bulgular cihazýn acil serviste kullanýmýnýn etkin olmadýðýný göstermiþtir. Ýlerleyen yýllarda artan deneyim ve çalýþmalar ile bu sonuç deðiþebilir.

BACKGROUND: This study aimed to discuss the effectiveness of Pneumoscan working with micropower impulse radar (MIR) technology in diagnosing pneumothorax (PTX) in the emergency department.
METHODS: Patients with suspicion of PTX and indication for thorax tomography (CT) were included into the study. Findings of the Thorax CT were compared with the results of Pneumoscan. Chi-square and Fisher’s exact tests were used in categorical variables.
RESULTS: One hundred and fifteen patients were included into the study group; twelve patients presented with PTX diagnosed by CT, 10 of which were detected by Pneumoscan. Thirty-six true negative results, sixty-seven false positive results, and two false negative results were obtained, which resulted in an overall sensitivity of 83.3%, specificity of 35.0% for Pneumoscan. There was no statistically significant difference between the effectiveness of Pneumoscan and CT on the detection of PTX (p=0.33). There was no difference between the size of PTX diagnosed by CT and PTX diagnosed by Pneumoscan (p=0.47). There was no statistically significant difference between Pneumoscan and CT on detecting the localisation of the PTX (p=1.00). For the 10 cases diagnosed by Pneumoscan, mean chest wall thickness was determined as 50.3 mm while mean chest wall thickness for two false negatives diagnosed by Pneumoscan was 56.5 mm. However, no statistically significant difference was found between the chest wall thickness and the effectiveness of Pneumoscan on the detection of the PTX (p=0.77). Among sixty-seven false positives diagnosed by Pneumoscan, 46.3% had additional medical signs such as bronchiectasis, pulmonary consolidation, pulmonary edema or pulmonary tumor when they had a reading with CT. The relationship between having additional medical signs at the reading with CT and the effectiveness of Pneumoscan on the detection of the PTX was investigated and no significant difference was found (p=0.472).
CONCLUSION: Using Pneumoscan to detect PTX is controversial since the device has a high false positive ratio. Wherein, false positive diagnosis can cause unjustifiable chest tube insertion. In addition, the device failed to show the size of the PTX, and therefore, it did not aid in determining the treatment and prognosis on contrary to traditional diagnostic methods. The findings could not demonstrate that the device was efficient in emergency care. Further studies and increasing experience may change this outcome in upcoming years.

AMAÇ: Eritrosit daðýlým geniþliði (EDG) deðeri tam kan sayýmýnýn bir parçasý olup dolaþýmdaki kýrmýzý kan hücrelerinin daðýlýmýnýn deðiþkenliðinin kantitatif bir ölçümüdür. EDG düzeyinin yüksek olmasý birçok hastalýkta mortalite ile iliþkili olduðu gösterilmiþtir. Bu çalýþmada yoðun bakýmda toplum kökenli intrabdominal sepsis nedeni ile takip ve tedavi edilen hastalarýn EDG deðerleri ile hastane mortalitesi arasýndaki iliþki araþtýrýldý.
GEREÇ VE YÖNTEM: 2010 Ocak–2013 Mart tarihleri arasýnda toplum kökenli karýniçi sepsis nedeni ile yoðun bakýma yatan hastalarýn demografik özellikleri, ek hastalýklarý, laboratuvar verileri ve APACHE-II skorlarý geriye dönük olarak deðerlendirildi.
BULGULAR: Çalýþmaya 55’i erkek, 48’i kadýn olmak üzere toplam 103 hasta alýndý. Hastalarýn yaþ ortalamasý 64.4±14 (SS), mortalite oraný ise %50.5 idi. Mortalite olan hastalarýn yoðun bakýma yatýþ anýndaki ortalama EDG (EDG1) deðeri ve APACHE-II skorlarý mortalite olmayan hastalardan daha yüksek idi. Lojistik regresyon analizinde sadece APACHE-II skoru ve EDG1 deðerlerinin istatistiksel olarak mortaliteyi etkilediði saptandý. ROC analizinde eðri altýnda kalan alan EDG1 için 0.867 (Güven aralýðý: 0.791–0.942) olarak, APACHE-II için ise 0.943 (Güven aralýðý: %95, 0.902–0.984) olarak saptandý.
TARTIÞMA: Bu çalýþmada artmýþ EDG deðerlerinin toplum kökenli karýniçi sepsisli yoðun bakým hastalarýnda mortalite ile iliþkili olduðu saptanmýþtýr.

BACKGROUND: Red cell distribution width (RDW) is a part of the complete blood count (CBC) panel reflecting quantitative measure of variability in the size of circulating red blood cells. It has been known that higher RDW is associated with increased mortality in several diseases. The aim of this study was to investigate the association between RDW and hospital mortality in intensive care unit (ICU) patients with community-acquired intra-abdominal sepsis (C-IAS).
METHODS: A retrospective analysis of the patients with C-IAS was performed between January 1, 2010 and March 31, 2013. Patients’ demographics, co-morbidities, laboratory measures including RDW on admission to the ICU, and Acute Physiologic and Chronic Health Evaluation II (APACHE II) score were analyzed.
RESULTS: A total of one hundred and three patients with C-IAS were included into the study with a mean age of 64±14 years. Overall mortality was 50.5%. RDW day 1 (RDW1) values and APACHE II scores were significantly higher in non-survivors than in survivors. In multivariate analysis, only RDW1 and APACHE II predicted mortality. The area under the receiver operating curves (AUC) of RDW1 and APACHE II were 0.867 (95% CI, 0.791–0.942) and 0.943 (95% CI, 0.902–0.984), respectively.
CONCLUSION: This study suggests that increased RDW is associated with mortality in ICU patients with C-IAS.

AMAÇ: Hýzlý sýralý enbütasyon sýrasýnda tek doz etomidat ve etomidat öncesi kullanýlan steroidin hemodinami ve kortizol seviyeleri üzerine etkisini araþtýrmayý amaçladýk.
GEREÇ VE YÖNTEM: Altmýþ hasta üç grubu ayrýldý (n=20). Entübasyon öncesi ve dördüncü ve 24. saatlerde, kortizol ölçümleri için kan örnekleri alýndý, hemodinamik parametreler (sistolik, diyastolik, ortalama arter basýncý, kalp atým hýzý) ve SOFA skorlarý not edildi. Entübasyon, Grup I’de 0.3 mg/kg IV etomidat ile, Grup II’de IV 2 mg/kg metilprednizolonu takiben 0.3 mg/kg etomidat ile, Grup III’de IV 0.15 mg/kg midazolam ile saðlandý.
BULGULAR: Ortalama arter basýncý deðerleri 24. saatte, Grup II ve Grup III’e göre Grup I’de daha düþüktü (p=0.009 ve 0.006). Grup I’de 24. saatte kalp atým hýzý Grup II ve Grup III’e göre yüksekti (p=0.005 ve p=0.001). Kortizol seviyeleri Grup I’de dördüncü (p<0.001 ve p<0.001) ve 24. saatlerde (p<0.001 ve p=0.001) Grup II ve III’e göre daha düþüktü.
TARTIÞMA: Acil þartlarda etomidat kullanýmýndan iki-dört dakika önce uygulanan metilprednizolon hýzlý sýralý entübasyon yapýlan hastalarda adrenal yetersizliði engelleyebilir. Ayrýca, midazolam düþük indüksiyon dozlarýnda etomidata alternatif olarak kullanýlabilir.

BACKGROUND: The study aimed to evaluate and compare the effects of a single dose of etomidate and the use of a steroid injection prior to etomidate during rapid sequence intubation on hemodynamics and cortisol levels.
METHODS: Sixty patients were divided into three groups (n=20). Before intubation, and at 4 and 24 hours, blood samples were taken for cortisol measurements and hemodynamic parameters (systolic-diastolic-mean arterial pressure, heart rate), and SOFA scores were recorded. Intubation was achieved with 0.3 mg/kg etomidate IV in Group I, 0.3 mg/kg etomidate following 2 mg/kg methylprednisolone IV in Group II, and 0.15 mg/kg IV midazolam in Group III.
RESULTS: Mean arterial pressure values were lower in Group I at the 24th hour when compared to Groups II and III. In Group I, heart rate values were higher compared to the other Groups. Cortisol levels were lower in Group I at the 4th and at the 24th hour in Groups II and III.
CONCLUSION: Administration of methylprednisolone 2–4 minutes prior to etomidate use in emergency situations can prevent adrenal insufficiency in patients undergoing rapid sequence intubation. Moreover, midazolam can be used in low induction doses as an alternative to etomidate.

AMAÇ: Pnömotoraks (PNX) pariyetal ve visseral plevra arasýna hava toplanmasý ve buna ikincil olarak geliþen akciðer sönmesi olarak tanýmlanýr. Risk faktörü olan kiþilerde kendiliðinden geliþebilir. Ancak genellikle künt veya penetran travma ile birliktedir. Taný genelde göðüs radyografisi (posteroanterior akciðer [PAAC] grafis) ile doðrulanýr. Göðüsün ultrasonografi (USG) ile incelenmesi travmalý olgularda PNX’in saptanmasýnda umut veren bir teknik olarak göze çarpmaktadýr. Acil serviste (AS) künt göðüs travmasý (KGT) ve PNX’in deðerlendirilmesi ile ilgili literatürde çalýþma sayýsý fazla deðildir. Bu çalýþmanýn amacý KGT ile AS’ye baþvuran hastalarda PNX tanýsýnda göðüs USG’nin etkinliðinin araþtýrýlmasýdýr.
GEREÇ VE YÖNTEM: Bu çalýþma bir üniversite hastanesi AS’sinde dokuz aylýk süre içerisinde yapýldý. Hastalara göðüs USG’leri bu konuda eðitimli acil týp hekimleri tarafýndan uygulandý. Sonuçlar anteroposterior akciðer (APAC) grafisi ve göðüs bilgisayarlý tomografisi (BT) ile karþýlaþtýrýldý. Anteroposterior akciðer grafisi ve/veya göðüs BT’si USG bulgularýna kör bir radyoloji uzmaný tarafýndan deðerlendirildi. Radyoloji uzmanýnýn deðerlendirmesi görüntüleme incelemelerinde taný için altýn standart olarak kabul edildi. Bilgisayarlý tomografi ile deðerlendirilmeyen hastalarda pnömotoraks tanýsý için klinik takip dikkate alýndý.
BULGULAR: Çalýþmaya alýnan 212 (144 erkek, 68 kadýn, ortalama yaþ 45.8) hastanýn tamamýna göðüs USG yapýldý. Ýki yüz on (%99) hastaya supin APAC grafisi, 120 (%56.6) hastaya ise göðüs BT çekildi. Tanýsý kesinleþen 25 (%11.8) PNX’in göðüs USG’de 22’si (%88), APAC grafisinde ise sekizi (%32) saptanabildi. Pnömotoraks tespit etmede göðüs USG’nin, klinik takip ve göðüs BT’ye göre duyarlýlýðý %88, özgüllüðü %99.5, olumlu öngörü deðeri %95.7 olumsuz öngörü deðeri ise %98.4 olarak bulundu.
TARTIÞMA: Çoðu merkezde PNX tanýsýnda supin ve ayakta akciðer grafisinin yerini henüz almayan, acil týp hekimleri tarafýndan yapýlan göðüs USG, PNX’in yatak baþý erken tanýsý için oldukça etkin ve önemli bir araçtýr.

BACKGROUND: Pneumothorax (PNX) is the collection of air between parietal and visceral pleura, and collapsed lung develops as a complication of the trapped air. PNX is likely to develop spontaneously in people with risk factors. However, it is mostly seen with blunt or penetrating trauma. Diagnosis is generally confirmed by chest radiography [posteroanterior chest radiography (PACR)]. Chest ultrasound (US) is also a promising technique for the detection of PNX in trauma patients. There is not much literature on the evaluation of blunt thoracic trauma (BTT) and pneumothorax (PNX) in the emergency department (ED). The aim of this study was to investigate the effectiveness of chest US for the diagnosis of PNX in patients presenting to ED with BTT
METHODS: This study was carried out for a period of nine months in the ED of a university hospital. The chest US of patients was performed by emergency physicians trained in the field. The results were compared with anteroposterior chest radiography and/or CT scan of the chest. The APCR and chest CT results were evaluated by a radiology specialist blind to US findings. The evaluation of the radiology specialist was taken as the gold standard for diagnosis by imaging methods. Clinical follow-up was taken into consideration for the diagnosis of PNX in patients on whom CT scan was not performed.
RESULTS: Chest US was performed on all two hundred and twelve patients (144 female and 68 male patients; mean age 45.8) who participated in this study. The supine APCR was performed on two hundred and ten (99%) patients and chest CT was performed on one hundred and twenty (56.6%). Out of the twenty-five (11.8%) diagnosed cases of PNX, 22 (88%) were diagnosed by chest US and 8 were diagnosed by APCR. For the detection of PNX, compared to clinical follow-up and chest CT, the sensitivity of chest US was 88%, specificity 99.5%, positive predictive value 95.7% and negative predictive value 98.4%.
CONCLUSION: Chest US has not superseded supine and standing chest radiography for PNX diagnosis yet in many healthcare centers, but it is performed by emergency physicians and it is an effective and important method for early and bedside diagnosis of PNX.

AMAÇ: Akut taþlý kolesistitte (ATK) tedavi seçeneði ve cerrahinin zamanlamasý hâlâ tartýþma konusudur. Tokyo Kýlavuzlarý (TG13) bazý kurallar teklif etmesine raðmen kanýta dayalý týptan (KDT) edinilen bilgileri tam olarak yansýtmamaktadýr. Çalýþma kýlavuzlarý uygulamamýza iliþkin bazý hususlara ve bunun klinik, ekonomik ve organizasyona iliþkin etkilerine dikkat çekmeyi amaçlamaktadýr.
GEREÇ VE YÖNTEM: Bu çalýþma idari veri tabanýyla birlikte klinik kayýtlardan gelen bilgilerin birleþtiði tek merkezli bir çalýþmadýr. 1 Ocak 2008 tarihinden 30 Nisan 2008’e kadar veriler toplandý. ATK’yi tedavi için tek cerrahlý yöntemden paylaþýmlý KDT yöntemine geçtiðimiz 15 Mayýs 2010’u referans noktasý olarak aldýk. Saðlýk hizmetlerinin geri ödemesi ve hastane maliyetlerini göz önüne alarak çalýþmanýn ekonomiyle ilgili yönü geliþtirildi.
BULGULAR: Ýki yüz üçü organizasyonda deðiþikliðe gitmeden önce (Grup 0) ve 299’u sonra (Grup 1) olmak üzere toplam 502 hasta seçildi. Grup 0’da hastalarýn %24.63’ü erken dönemde laparoskopik kolesistektomi (ELK) ile tedavi edilirken %39.4’üne ikinci kez geliþlerinde geç dönemde (GLK) cerrahi uygulandý. Deðiþiðe gittikten sonra hastalarýn %57.5’i ELK ve %13’ü GLK ile tedavi edilmiþtir. Deðiþiklikten sonra hastanede ortalama kalýþ süresi anlamlý derecede daha kýsa (9.5 ve 7.3 gün, p<0.0001) olup komplikasyonlar açýsýndan herhangi bir fark izlenmedi.
TARTIÞMA: Klinik pratiðe kanýta dayalý týp uygulamasý daha iyi sonuçlar alýnmasýna neden olmuþtur. Ekonomik açýdan klinik deðiþiklik maliyetlerle hastaneye geri ödeme arasýnda olumlu bir farklýlýkla birlikte kaynaklarýn doðru kullanýlmasýna yol açmýþtýr.

BACKGROUND: Treatment option and timing for surgery in case of acute calculous cholecystitis (ACC) is still a matter of discussion. Tokyo Guidelines (TG13) offers some rules but they don’t reflect entirely the information of Evidence Based Medicine (EBM). This study aimed to draw some consideration from our practice in the application of the guidelines and put forward the clinical, economic and organizational effect of it.
METHODS: The study is a single center retrospective study based on administrative database formed by gathering information from clinical registry. Data were collected between January 1st, 2008 and April 30th, 2013. A cutoff point was established on May 15th, 2010 when we moved from a single surgeon method to a shared EBM method to treat ACC. The economic aspect was developed considering health service reimburse and hospital costs.
RESULTS: Five hundred and two patients were selected, 203 patients before the organizational change (Group 0) and 299 after (Group 1). In Group 0, 24.63% of the patients were treated with early laparoscopic cholecystectomy (ELC) and 39.4% received surgery delayed in second admission (DLC). After the change, 57.5% of the patients were treated with ELC while 13% were treated with DLC. Median length of stay (LOS) was significantly lower after the change (9.5 vs. 7.3, p<0.0001), and no difference in terms of complication was noticed.
CONCLUSION: Application of evidence based medicine in clinical practice resulted in better results. Economically, the clinical change resulted in a proper use of resources with a positive gap between the costs and refund to the hospital.

AMAÇ: Safra taþý hastalýðý geliþmiþ ülkelerde sýk görülen bir sorundur. Eriþkinlerin en az %10’unda safra taþý vardýr. Safra taþý olan insanlarýn %40–60’ý semptomsuz klinik seyir gösterirken, semptomlu kolelitiazisi olan olgularýn çoðunda da semptomsuz bir dönem bulunur. Semptomlu safra taþlarýnýn %20’si akut kolesistit tablosu ile acil servislere baþvurur. Bu çalýþmada, akut kolesistitli olgularda, pentraksin 3 (PTX3) düzeylerin komplikasyonlar ve prognoz üzerindeki tanýsal deðerini belirlemeyi ve akut kolesistit olgularýnda morbidite ve mortalite oranlarýný azaltmayý amaçladýk.
GEREÇ VE YÖNTEM: Bu çalýþma Atatürk Üniversitesi Týp Fakültesi Genel Cerrahi Servisi’nde Eylül 2012–Ocak 2014 tarihleri arasýnda akut taþlý kolesistit tanýsý konulup ameliyat edilen hastalar üzerinde yapýldý. Çalýþmaya yaþlarý 18’den büyük, klinik ve radyolojik olarak akut taþlý kolesistit tanýsý konmuþ 45 hasta (Grup I) ve 18 yaþ üstü 45 saðlýklý (Grup II) kiþi alýndý. Olgular randomize olarak seçildi.
BULGULAR: Çalýþmamýzda plazma PTX3 düzeyinin hasta grubunda ve morbidite geliþen hastalarda yüksek olmakla birlikte istatisitiksel olarak anlamlý deðildi. Pentraksin 3 deðerlerinin ileri yaþ hastalarda anlamlý olarak arttýðý saptandý (p<0.05). Ayrýca hastanede yatýþ süreli karþýlaþtýrýldýðýnda PTX3’ün hastanede daha uzun süre yatan hastalarda daha yüksek olduðu belirlendi (p<0.05).
TARTIÞMA: Pentraksin 3 düzeyleri akut kolesistitli hastalarda deðerlendirilen tüm parametrelerde yüksek bulundu. Bu yüzden PTX3 düzeyleri akut kolesistitte taný ve prognoz tahmininde deðerli bir gösterge olabilir.

BACKGROUND: Cholelithiasis is a frequently encountered problem in developed countries. Gallstone is present in at least 10% of the adults. While 40–60% of people with gallstones manifest an asymptomatic clinical course, in most of the cases with symptomatic cholelithiasis, there is also an asymptomatic period. 20% of the patients with symptomatic gallstones are admitted to emergency services with clinical features of acute cholecystitis. In this study, our aim was to evaluate the diagnostic value of pentraxin 3 on complications and prognosis and also to reduce the morbidity and mortality rates in cases with acute cholecystitis.
METHODS: This study was conducted on patients diagnosed with acute calculous cholecystitis and operated on between September 2012 and January 2014, in the Department of General Surgery of Atatürk University Medical Faculty. Forty-five patients with ages above 18, who were clinically and radiologically diagnosed with acute calculous cholecystitis (Group I) and 45 healthy people, older than 18 (Group II) were included into the study. Patients were randomly selected.
RESULTS: In our study, although the plasma pentraxin 3 (PTX3) levels were increased in the patient group and also in patients who developed morbidity, this was not statistically significant. PTX3 values were determined to be significantly increased in older patients (p<0.05). Moreover, when the duration of hospital stays were compared, PTX3 was found to be significantly higher in patients hospitalized for longer periods (p<0.05).
CONCLUSION: PTX3 levels were found to be elevated in all evaluated parameters in patients with acute cholecystitis. Therefore, PTX3 level may be a valuable indicator in diagnosis and also in predicting prognosis.

AMAÇ: Kalça çivileme (PFN) yaþlý hastalardaki instabil intertrokanterik femur kýrýklarýnýn (ITF) tedavisinde sýklýkla kullanýlmaktadýr. Bu geriye dönük çalýþmada, kýrýk sahasýnda kompresyona izin veren birbirine entegre, birbirine kilitlenebilir kompresyon lag vidasý kiti ya da iki ayrý lag vidasý kullanýlan PFN ile tedavi edilmiþ olan hastalarýn fonksiyonel, radyolojik sonuçlarý ve komplikasyonlarý karþýlaþtýrýldý.
GEREÇ VE YÖNTEM: Mayýs 2010 ve Nisan 2012 tarihleri arasýnda, AO/OTA 31–A2 ITF kýrýðý için ameliyat edilmiþ olan 118 hastadan takipleri ve kayýtlarý yeterli olan 82’si incelendi. Kompresyon yapabilen, birbirine kilitlenebilir, entegre lag vidasý kiti olan PFN (Grup I) 44 hastada, iki ayrý lag vidasý olan PFN ise (Grup II) 38 hastada kullanýldý. Sonuç parametreleri radyolojik olarak varusta çökme ve bacak boyu eþitsizliði, fonksiyonel olarak da Batý Ontario ve McMaster Üniversiteleri artrit indeksi (WOMAC) ve Harris kalça skorlarý (HHS) idi.
BULGULAR: Ortalama takip süresi olan 20 (12–36) ayda tüm kýrýklar iyileþti. Grup I ve Grup II’de sýrasýyla, ortalama varus çökmesi 2.03° ve 5.21° (p=0,01), ortalama HHS 73,2 ve 74,72 (p=0,54), ortalama WOMAC skorlarý ise 70,78 ve 71,78 (p=0,69) olarak bulundu. Sonuç parametreleri ve komplikasyon oranlarý bakýmýndan gruplar arasýnda anlamlý bir fark görülmedi (p>0.05).
TARTIÞMA: Ýntertrokanterik femur kýrýklarýnýn tedavisinde, birbirine entegre ve birbirine kilitlenebilir kompresyon lag vidasý veya iki ayrý lag vidasý kullanýlan PFN’ler arasýnda fonksiyonel, radyolojik sonuçlar ve komplikasyon oranlarý açýsýndan fark bulunmamaktadýr.

BACKGROUND: Hip nailing is frequently used to treat unstable intertrochanteric femoral fractures (ITF) in elderly patients. In this retrospective study, we compared the functional and radiological results, and the complications, of patients treated using proximal femoral nails (PFN) with an integrated, interlocking, compression lag screw, or two separate lag screws, which allow linear compression at the fracture site.
METHODS: A total of one hundred and eighteen patients were operated on for AO/OTA 31-A2 ITF between May 2010 and April 2012, and eighty-two of these patients, for whom sufficient follow-up data and documentation were available, were included into the study. PFNs with interlocking, integrated lag screws (Group I) were used in forty-four patients, and PFNs with two separate lag screws (Group II) in thirty-eight. Outcome parameters were the extent of varus collapse and leg length discrepancy on radiographs, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Harris hip scores (HHS) as functional results.
RESULTS: Mean follow-up duration was 20 months (range, 12–36 months); fractures healed in all patients. Mean varus collapse values were 2.03±5.68° and 5.21±5.27° (p=0.01), Harris hip scores 73.2±11.65 and 74.72±11.15 (p=0.54), and WOMAC scores 70.78±11.41 and 71.78±11.19 (p=0.69) in Groups I and II, respectively. No difference was detected between the groups in terms of outcome parameters or complication rate.
CONCLUSION: In the treatment of ITF, PFNs with an integrated, interlocking, compression lag screw, or two separate lag screws did not differ in terms of functional and radiological results or complication rate.

AMAÇ: Pelvis kýrýklarý çocukluk çaðýnda nadir görülen, hayati tehlike arz eden ve ayný zamanda sekel býrakma ihtimali yüksek olan yaralanmalardýr. Doku elastisitesi, kaynama kapasitesi ve remodelasyon yetenekleri eriþkinlere göre daha yüksek olduðundan pelvis kýrýklarýnýn prognozu çocuklarda eriþkinlere göre daha iyidir. Kaynamama nadir görülürken, kötü kaynama ise genellikle çocuklar tarafýndan iyi tolere edilir. Bu çalýþmada, tek bir travma merkezinde tedavileri sürdürülmüþ hastalarý geriye dönük olarak inceledik ve literatür bilgileri ýþýðýnda tartýþtýk.
GEREÇ VE YÖNTEM: Hasta dosyalarý taný, yaralanma mekanizmasý, ek yaralanmalar, uygulanan tedavi metotlarý ve komplikasyonlar açýsýnda incelendi. Kýrýklar Torode ve Zieg’in tarif ettiði sýnýflandýrmaya göre sýnýflandýrýldý. Hastalar kayýtlý telefonlarýndan son bir inceleme için geri çaðýrýldý.
BULGULAR: 1997 ve 2012 yýllarý arasýnda, ortalama yaþlarý 6.8±2.4 olan, 28 hastanýn acil kliniðimize baþvurduðu tespit edildi. Baþvuru anýnda tüm hastalar 12 yaþ altýnda idi. Üç hasta instabil pelvis kýrýðý (tip 4) tanýsý ile acil þartlarda ameliyat edildi. Bir hasta ameliyat sonrasý erken dönemde pelvis içi aþýrý kanamaya baðlý kaybedildi. Ortalama 5.3±3.6 yýl takip neticesinde 27 hastanýn ciddi bir sekel kalmadan normal hayatlarýna devam ettikleri görüldü.
TARTIÞMA: Pediatrik pelvis kýrýklarý nadir görülen ancak ciddi morbidite ve mortalite riski olan yaralanmalardýr. Doðru zamanlama ve uygun tedavi ile uzun dönemde iyi klinik sonuçlar gözlenmektedir.

BACKGROUND: Although pediatric pelvis fractures are relatively uncommon, long-term consequences and associated life-treating injuries often have a substantial impact for the rest of a child’s life. The prognosis of pediatric pelvic fractures is better than that of the adults because of their greater elasticity, healing capacity and re-modelling. Fractures through the physis may lead to growth disturbance and/or acetabular dysplasia. Non-union is rare and mal-union is usually well-tolerated. The purpose of this study was to evaluate the results of a single trauma center and review the literature approach to pediatric pelvic fractures.
METHODS: Medical records were analyzed for diagnosis, the mechanism of injury, additional injuries, treatment methods, and complications. The types of fractures were classified according to Torode and Zieg classification. Patients were called back and seen at the clinic as a last follow up visit.
RESULTS: Twenty eight skeletally immature patients, under the age of 12, were treated for pelvic fracture from 1997 to 2012. Mean age was 6.8±2.4 years. Three children with an unstable pelvic ring injury required pelvic external fixation. One patient died due to pelvic hemorrhage postoperatively. Mean follow up was 5.3±3.6 years.
CONCLUSION: Pediatric pelvic fractures are rare but life-threating injuries. Overall good or excellent long-term results can be expected in most cases with appropriate timing and treatment.

Tibia kýrýklarý ortopedik yaralanmalar içinde en sýk görülen kýrýklardan biridir. Çoðu yüksek ivmeli travma sonucu oluþmaktadýr. Tibia diyafiz kýrýklarýnda intramedüller çivileme bu olgularda altýn standart tedavi olarak kabul edilse bile bu çiviyle tespit yöntemiyle birçok metafiz ve metafiz-diyafiz bileþke kýrýklarý da tedavi edilebilmektedir. Cerrahi iþlem sýrasýnda bu kýrýklarda hizalanmanýn saðlanmasý, patella tendonundaki çekilme, cerrahi iþiem için diz fleksiyona getirilir getirilmez proksimal fragmaný uzatma eðiliminde olduðundan sýklýkla zordur. Literatürde bu kýrýklarýn çivilemeyle baþarýlý tespit edilmesi için diðer yöntemler arasýnda yarý-uzatýlmýþ çivileme, iç yan plaklarýn ve eksternal fiksatörün kullanýlmasý gibi sayýsýz teknik modifikasyon tanýmlanmýþtýr. Bu yazýda, kýrýðýn hizalanmasýný saðlamak için yaratýcý bir eksternal fiksatör uyguladýðýmýz ve tibia metafiz kýrýklarýnýn konvansiyonel kapalý yöntemle intramedüller çiviyle tespitine tüm süreç boyunca devam edilen iki olgu sunuldu. Kapalý cerrahi sýrasýnda ve sonrasýnda ameliyat sonrasý radyografilerde gözlendiði gibi iyi bir hizalama saðladýk. Baþka teknikleri uygulamaktan kaçýnmak isteyen cerrahlara yardýmcý olmak için bu tekniðin ileri deðerlendirmelerinin yararlý olabileceðine inanmaktayýz.

Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.

Kostik kimyasallar ilk temastan çok uzun süre sonra bile dokuda hasara neden olurlar. Bu yazýda, sodyum hidroksit yanýk olgusunda tedavisi sýrasýnda gözlenen tekrar eden greft kaybý sunuldu. Hastanýn ayak bileðindeki kostik yanýk dört aylýk dönem içinde üç kere kýsmi kalýnlýkta deri grefti ile onarýldý. Her greftlemeden sonra yanýk bölgesi sorunsuz olarak iyileþti. Ancak baþarýlý olan her bir greftlemeden haftalar sonra, hastanýn ameliyat edilen ayak bileði travmaya maruz kalmamasýna raðmen, deri grefti uygulanan bölgede ekzematöz blister oluþumu gözlendi. Bunun ardýndan baþarýlý greftleme ve iyileþmeye raðmen deri greftleri tamama yakýn oranda soyuldu. Ýlk yanýktan ve tekrar eden deri grefti kayýplarýndan altý ay sonra defekt alaný medial plantar flep ile onarýldý. Flep ameliyatý ardýndan dokuzuncu ay takibinde yanýk alanýnda herhangi bir blister oluþumu bulgusu veya deri kaybý gözlenmedi. Tamamen baþarýlý olmuþ deri grefti uygulamasý ardýndan birkaç hafta içinde tekrar eden greft kayýplarý gözlenmesi pek çok yanýk olgusu için sýradýþý bir komplikasyondur. Kostik yanýklar dokuya zarar vermeye devam eden kimyasal reaksiyonlarý gizleyen aldatýcý bir yüzeysel görünüme sahip olabilir. Bu nedenle ilk tedavi seçeneði olarak derin debridman ve greft cerrahisi gibi erken cerrahi müdahaleler akýlda bulundurulmalýdýr.

Caustic chemicals cause destruction in tissues even long after the initial exposure. This study reported a case of recurrent graft lysis encountered throughout the treatment of a sodium hydroxide burn. A caustic burn on the ankle of a patient was reconstructed with split thickness skin grafts thrice in a period of four months. The burn site healed uneventfully after each skin grafting. However, weeks after each successful graft take, even though the patient did not experience any trauma at his operated ankle, an eczematous blistering at the skin graft site was observed. Thereafter, skin grafts almost totally sloughed over time even after each successful graft take. Six months after the initial burn and recurrent skin graft lysis, the defect site was reconstructed with medial plantar flap. At the postoperative ninth month follow-up, there was no sign of the blistering or skin loss at the burn area after definitive flap surgery. Recurrent graft lysis, in a few weeks after total skin graft take is an unusual complication for most of the burn cases. Caustic burns may have a deceptively superficial appearance concealing the chemical reactions that further damage the tissue. Therefore, early surgical interventions such as deep debridement and graft surgery should be kept in mind as primary treatment options.

Ekstraplevral hematom oldukça nadir bir klinik durumdur ve etiyolojisinde en sýk künt toraks travmasý, santral venöz kateterizasyon ve torasik aort anevrizmasý rüptürü bulunmaktadýr. Burada ekstraplevral hematom nedeniyle video-yardýmlý torakoskopik cerrahi ile tedavi ettiðimiz üç olguyu sunduk. Bu olgularda etiyolojik faktörler; iki olguda yüksekten düþme ve bir olguda sað internal juguler vene yerleþtirilen diyaliz kateteri idi.

Extrapleural hematoma is a rare clinical condition whose most common causes are blunt chest trauma, central venous catheterization and ruptured thoracic aortic aneurysm. This study aimed to present three cases that underwent video-assisted thoracoscopic surgery due to extrapleural hematoma. Etiologic factors in these cases were falls from height in two cases and a dialysis catheter placed into the right internal jugular vein in one case.

Doðumsal mezenter defektler oldukça nadir; bir kýsmý ömür boyu fark edilemeyen bir kýsmý ise ameliyat veya otopsi esnasýnda tanýnabilen, ameliyat öncesi tanýnma olasýlýðý çok düþük olan patolojilerdir. Genellikle gýda alýmýný takiben, zaman zaman ortaya çýkan karýn aðrýsý ve baðýrsak týkanýklýðý bulgularý veren, daha önce karýn ameliyatý ve karýn içi enfeksiyon geçirmemiþ olgularda bu patolojinin akla gelmesi, erken taný ve cerrahi giriþim, morbidite ve mortalite oranlarýný etkileyen en önemli unsurlardýr. Bu yazýda 20 yaþýnda, ameliyat öncesi bilgisayarlý tomografi ile tanýsý koyulabilmiþ bir kadýn olgu literatür bilgileri ýþýðýnda sunuldu.

Congenital mesenteric defects are rare and often recognized only in surgery or autopsy. Preoperative diagnosis of an internal hernia is quite rare. A common symptom of trans-mesenteric intestinal herniation is intermittent postprandial pain. If there is strangulation of the mesenteric internal herniation, there is often vomiting and constipation. Signs and symptoms of a bowel obstruction in a patient without previous abdominal surgery or inguinal hernia as well as without history of intra-abdominal operation and infection suggest the possibility of a congenital mesenteric defect with internal herniation. Early diagnosis and surgical treatment are important to reduce morbidity and mortality. This study aimed to present the case of a 20-year-old female patient on whom preoperative diagnosis of internal trans-mesenteric internal hernia was made.

Mezenter ven trombozu nadir görülen fakat mortalitesi yüksek olan bir hastalýktýr. Klinik belirtilerinin semptomsuz olmasý nedeniyle taný koymak güçtür. Taný çoðunlukla laparotomi veya otopsi ile konur. Mezenter ven trombozu etiyolojisinde birçok faktör sayýlmaktadýr. Olgumuzda otopsi ve histopatolojik inceleme ile tespit ettiðimiz karaciðer sirozu ve kronik piyelonefrit bu nedenler arasýnda sayýlmaktadýr. Bu çalýþmada, V. lienalis, V. pankreatika ve süperior mezenterik ven dallarýnýna kadar uzanan portal ven trombozuna baðlý tama yakýn ince baðýrsak nekrozu geliþmiþ olan olgu sunuldu.

Mesenteric venous thrombosis is a rare disorder with a high mortality rate. Since patients remain asymptomatic, diagnosis of the disease is difficult. Diagnosis can be mainly made with either laparotomy or autopsy. Many factors are considered in the etiology of mesenteric venous thrombosis. Liver cirrhosis and chronic pyelonephritis, which we detected in the autopsy and histologic examination of our case, are considered as two of the factors. In our study, it was aimed to present a case with near-total intestinal necrosis caused by portal vein thrombosis which spread to the lineal vein, pancreatic vein and to the branches of superior mesenteric veins.