Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer

Background and aims The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. Patients and methods Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16–85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer–Lemeshow goodness-of-fit test, respectively. Results Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. Conclusions MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.     

Intestinal parasitic infestation in pediatric gastroenterology outpatient clinic Dr. Pirngadi Hospital Medan

A retrospective study had been done at the outpatient clinic sub division of Pediatric Gastroenterology, Dr. Pirngcdi Hospital Medan, comprising patients from 1 January 1985-31 December 1987. There were 874 patients. Three hundred seventy eight (43.25%) patients consisting of 210 (55.56%) males and 168 (44.44%) females had intestinal parasitic infestations. The youngest patient was 5 months and the oldest was 14 years and 3 months. Ascaris lumbricoides was found in 215 patients (24.60%) while Trichuris trichiura, hookworm, Oxyuris vermicularis, Hymenolepis nana, and Taenia were in 152 (17.39%), 13 (1.49%), 4 (0.46%), 15 (1.72%) and 4 (0.46%) cases respectively. Entamoeba histolytica was found in 121 (13.84%) and Giardia lamblia in 16 (1.83%) patients. The highest age specific attack rate was found in the age group of 5-10 years (65.67%). Ascaris lumbricoides was most frequently found namely in 100 children (26.46%), followed by Entameba histolytica in 73 (19.31%) and mixed infestation of Ascaris lumbricoides and Trichuris trichiura in 68 (17.99%) patients. One hundred seventy three (66.28%) under five patients with intestinal parasitic infestation had malnutrition while of the 433 under fives without intestinal parasitic infestation only 201 (46.42%) suffered from malnutrition (P less than 0.001).     

Abdominal Stab Wounds in Children: an 18-Year Experience

Objective: Evaluation of the diagnosis, management, and the role of selective treatment in children with abdominal stab wounds. Patients and Methods: 59 children (56 male and three female) were included in the study. The patients' median age was 11.8 years (range, 5–14 years). Time between injury and admission was about 3 h. Laparotomy was performed in 44 patients (74%). Solid organ injury was detected in 32 of these patients (73%) and could not be observed in twelve (27%). 15 patients (26%) were treated conservatively, and only one (6.6%) underwent laparotomy during the follow-up. The stomach was the most frequently injured organ (ten patients), followed by the intestines (nine patients). Types of surgical treatment were as follows: primary suture in 28 patients, resection-anastomosis in three, and osteotomy in two. Results: Some prognostic factors such as presence of abdominal organ evisceration and pneumoperitoneum were not significantly correlated with intraabdominal organ injury, whereas some other risk factors such as acute abdomen on admission (p < 0.002) or abdominal clinical and hemodynamic findings (p < 0.001) showed significant correlation with intraabdominal organ injury. The relative risk (odds ratio) of developing an intraabdominal organ injury was > 2 for patients with signs of an acute abdomen on admission. Postoperative complications were observed in five patients with organ injuries. None of our patients died. Conclusions: Conservative treatment can be safely performed in most children with abdominal stab injuries. Signs of major internal hemorrhage or generalized peritonitis are an absolute indication for emergency operation for abdominal stab wounds. Peritoneal penetrations, free air on the abdominal X-ray, and omental or intestinal evisceration are poor indicators of significant organ injuries, and patients presenting these signs shold be closely followed up for developing acute abdominal symptoms. Received: November 2, 2001; revision accepted: February 15, 2002     

Block of sodium channels by tyramine and its analogue (N-feruloyl tyramine) in frog ventricular myocytes.

Pharmacological effects of tyramine and its analogue, N-feruloyl tyramine (NFT), on sodium and calcium currents in frog ventricular myocytes were examined using the whole-cell voltage-clamp technique. To improve the temporal and spatial control of the membrane potential, sodium currents (INa) were recorded in 45.5 mM [Na+]o at 10 degrees C. Both tyramine and NFT (1-100 microM) induced a concentration-dependent decrease in INa evoked from a holding potential of -80 mV without affecting a change in either the time to peak or the time constant for the falling phase of INa. Similarly the reversal potential for INa remained unchanged at a value close to that predicted from the Nernst equation. The finding that both tyramine and NFT decreased INa when activated maximally, from a holding potential of -120 mV, indicates that the amplitude of INa can be reduced independently of a change in the kinetics of the current. In addition, tyramine (100 microM) shifted the membrane potential for half maximal inactivation (Vh) of the steady-state inactivation (h infinity)-curve from -74 to -84 mV without affecting its slope. In contrast, NFT failed to affect the h infinity-curve. The calcium current (ICa) recorded in the presence of 0.3 microM TTX was not affected by either 100 microM tyramine or NFT. We concluded that tyramine directly blocks Na channel by shifting h infinity-curve and by suppressing maximum Na channel conductance, while NFT suppresses only maximum Na channel conductance.     

Human lymphocyte antigens (HLA) and Graves' disease in Turkey

To evaluate the association of HLA types with Turkish patients with Graves' disease, HLA typing, clinical findings, and thyroid antibodies were correlated. The HLA types, clinical findings (ophthalmopathy and age at onset), and thyroid stimulating hormone (TSH) receptor (TRAb) and antithyroid microsomal antibodies (MAb) were analyzed. Seventy Turkish patients with Graves' disease and 306 control subjects were assessed. Serological HLA typing was performed in HLA A, B, C, DR, and DQ loci. There was a significantly increased prevalence of HLA B8, B49, DR3, DR4, and DR10 in Graves' disease. The association of Graves' disease with HLA DR3 was found to be less strong than previously described. The HLA DR4 antigen may contribute to the predisposition of Graves' disease in Turkey. The results suggest that HLA B7, B13, DR7, DQw2, and DQw3 may confer a protective effect for Graves' disease in Turkey. Patients carrying HLA B12, B18, and B44 haplotypes had a tendency to develop the disease at a later age. The difference from the other studies may be the result of the selection of the controls; in part, of the variability in serological typing reagents; and, also, of the rather weak HLA associations with the disease.This study was presented in part at the Annual Meeting of the National Endocrinology and Diabetes Association, Bursa, Turkey, May 25–28, 1992.     

Changes in cyclic nucleotides during the calcium paradox in the isolated rat heart

Reperfusion of hearts with a Ca²⁺-containing medium after a perfusion period in Ca²⁺-free medium results in irreversible cell damage (calcium paradox). In this investigation we have studied coronary flow and cyclic AMP and cyclic GMP levels after several periods of Ca²⁺-free perfusion in isolated rat hearts. We also investigated the effects of papaverine (Pap), noradrenaline (NA), acetylcholine (ACh) and absence of inorganic phosphate during Ca²⁺-free perfusion on coronary flow (CF) and cyclic nucleotide levels. Inability of the heart to recover contractile activity with development of contracture during the reperfusion period was accepted as indicative of the calcium paradox. Ca²⁺-free perfusion alone and NA and absence of inorganic phosphate during the Ca²⁺-free perfusion period increased CF, whereas Pap and ACh decreased it. However, only Ca²⁺-free perfusion and NA elevated cyclic AMP. On the other hand, Pap and ACh increased cyclic GMP (with a transient rise of cyclic AMP in Pap infusion), and absence of inorganic phosphate decreased both cyclic AMP and cyclic GMP. Pap, ACh and absence of phosphate prevented the calcium paradox. Our study suggests that increased cyclic AMP during the Ca²⁺-free perfusion may contribute, with the other factors, to the occurrence of the calcium paradox.     

Right ventricular free wall perforation during pericardiocentesis,and an inappropriate device selection for percutaneous treatment

Right ventricular (RV) perforation is a rare but life‐threatening complication of pericardiocentesis and is usually treated surgically. We presented a case of RV free wall perforation, which occurred during pericardiocentesis and tried to be closed percutaneously with the Amplatzer vascular plug‐III (AVP‐III) device. The occluder device sealed the perforation, but it was in an insecure position; therefore, the patient underwent surgical repair. As an AVP‐III device, with a middle disk thicker than the RV myocardium, it may cause the RV myocardium to stretch outwards, so it should not be used for the treatment of RV perforation by the transcatheter way.     

Seismic upgrades of healthcare facilities

Before 1989 seismic upgrading of hospital structures was not a primary consideration among hospital owners. However, after extensive earthquake damage to hospital buildings at Loma Prieta in Northern California in 1989 and then at Northridge in Southern California in 1994, hospital owners, legislators, and design teams become concerned about the need for seismic upgrading of existing facilities. Because the damage hospital structures sustained in the earthquakes was so severe and far-reaching, California has enacted laws that mandate seismic upgrading for existing facilities. Now hospital owners will have to upgrade buildings that do not conform to statewide seismic adequacy laws. By 2030, California expects all of its hospital structures to be sufficiently seismic-resistant. Slowly, regions in the Midwest and on the East Coast are following their example. This article outlines reasons and ways for seismic upgrading of existing facilities.     

Amebic Liver Abscess: Changing Trends over 20 Years RID="" ID="" This study was presented to the Turkish Surgical Congress in Izmir, Turkey.

RID=" ID=" <E5>Correspondence to:</E5> Y. Akgun, M.D.