Outpatient follow-up' or 'Active clinical observation' in patients with nonspecific abdominal pain in the Emergency Department. A randomized clinical trial

AIM: The aim of this study was to determine whether it is safe and cost-effective to discharge nonspecific abdominal pain (NSAP) patients from the Emergency Department (ED) and re-evaluate diagnosis later. METHODS: Patients aged between 18 and 65 years were enrolled into the study. They had been admitted to the ED for acute abdominal pain with an indefinitive diagnosis after clinical examination and base-line investigations. The patients were randomly assigned into two groups: 1) active clinical observation (ACO), comprising those admitted to the ED observation room; 2) outpatient group (OG), comprising those discharged and asked to return for re-evaluation at 8-12 hours intervals over the following three days. Each patient was examined by an ED physician and a consultant general surgeon. Demographics, blood tests, morbidity and mortality, number of operations, together with 6-month follow-up results were noted. Finally, a patient satisfaction questionnaire was administered. RESULTS: A total of 105 patients were enrolled into the study; 50 were randomized to the ACO group and 55 to the OG. There were no statistically significant differences in demographics and blood parameters between the two groups. Overall agreement of ED diagnosis with final diagnosis was 91.4%. Total morbidity was 10% in the ACO group and 7.2% in the OG. There were no statistically differences in morbidities and usage of diagnostic imaging modalities between the two groups (P>0.05). No deaths occurred in either group during the study period. The patients in the ACO group were more keen on returning for re-evaluation and willing to recommend our hospital services to other people (P< or =0.05). CONCLUSION: Outpatient evaluation of patients with an ED diagnosis of NSAP may be an option, seems to be safe, is not accompanied by an increased incidence of complications and is efficient if patients are selected properly.     

Ecstasy-induced recurrent toxic hepatitis in a young adult

BACKGROUND: The drug 3,4-methylenedioxymethamphetamine (MDMA), otherwise known as “ecstasy,” is a synthetic amphetamine that produces euphoria, increases sociability and energy, and is often used as a “weekend” recreational drug by young adults.CASE SUMMARY: A 23-year-old male (height, 184 cm; weight, 68 kg) presented to the emergency department of Marmara University Hospital, Istanbul, Turkey, with jaundice and nausea lasting for 6 days. The patient reported that he had been a chronic user of MDMA for 2 years. He also reported that 1 week before presenting, he had ingested twice (2 tablets) the usual amount (1 tablet) of the drug at the same time. Blood tests were performed and hematologic findings were as follows: aspartate aminotransferase (AST), 1423 U/L (reference range, 10-37 U/L); alanine aminotransferase (ALT), 2748 U/L (10-40 U/L); alkaline phosphatase, 271 U/L (0-270 U/L); γ-glutamyl transpeptidase, 124 U/L (7-49 U/L); total bilirubin, 13.23 mg/dL (0.2-1 mg/dL); direct bilirubin, 8.75 mg/dL (0-0.3 mg/dL); amylase, 80 U/L (0-220 U/L); prothrombin time, 21.2 sec; activated partial thromboplastin time, 37.3 sec; and international normalized ratio, 1.66. Liver enzymes and bilirubin levels were found to be extremely high (AST = 40x normal, ALT = 70x normal, and bilirubin = 13x normal). Viral, autoimmune, and metabolic causes were excluded. Serologic tests for hepatitis A, B, and C viruses, mononucleosis, cytomegalovirus, and HIV infection were all negative. A diagnosis of ecstasy-induced toxic hepatitis was made. The patient's medical history further revealed that the current incident was actually his second occurrence of jaundice and acute hepatitis associated with the ingestion of higher amounts (twice the usual amount of MDMA he ingested at the same time). Supportive therapy (IV saline and vital sign monitoring) was initiated and liver enzymes, bilirubin levels, and prothrombin times were monitored daily. All had returned to normal values in 2 weeks.CONCLUSIONS: MDMA, or the recreational drug ecstasy, might be responsible for acute hepatitis and/or acute liver failure, particularly in young people. Physicians might need to be alert to the possibility of ecstasy-induced liver damage occurring in younger patients, although the presence of other hepatotoxins and alternative diagnoses requires exclusion. The use of this drug should be investigated in young patients with severe hepatitis of unknown origin.     

Bilateral lumbosacral plexopathy after femoral vein dialysis: synopsis of a case

Femoral vein dialysis is a technique applied in many clinics. Hemorrhagic complications following the procedure either directly due to the femoral catheterization itself in the early period or less with concomitant late neurological impairments may pose serious challenges to the clinician. Likewise in this report, we are presenting a dialysis patient with bilateral retroperitoneal hematomas causing bilateral lumbosacral plexopathies-to our best knowledge the first in the literature. We have also touched upon its prompt diagnosis and treatment.     

An effect of actin on cell migration

A specific inhibitory effect on mononuclear cell migration by smooth muscle actin and skeletal muscle actin is reported. Actin aged at 4 degrees C or heated at 56 degrees C for 10 min had little or no effect, but papain-denatured actin had a strong inhibitory action. Actin and/or its breakdown product(s) may interfere with mononuclear cell movement in vivo in pathological conditions where release of actin from damaged or dead cells occurs.     

Biliary complications after hydatid liver surgery: Incidence and risk factors

The aims of this study were to determine the incidence and risk factors of biliary leakage and biliary fistu lae after hydatid liver surgery and to suggest preventive precautions. From January 1999 to June 2000, 70 cysts were examined from 54 patients who were operated on for hydatid liver disease. Age, sex, primary or recurrent disease, liver function tests, number, location, content, radiological type, and diameter and cav ity management techniques were examined with univariate and multivariate analyses for biliary complica tions. Biliary leakage occurred in 14 cysts (26%) from the patients. Purulent and/or bilious cyst content (61.9% vs. 2.0%; P = 0.022), male gender (40.9% vs. 10.4%; P = 0.038), and pre-operative raised alka line phosphatase and gamma glutamyl transferase levels (34.6% vs. 11.4%; P = 0.047) were found as in dependent risk factors for post-operative biliary leakage. Nine instances of biliary leakage (16.7%) closed spontaneously within seven days. The remaining five instances of biliary leakage (9.3%) persisted for more than 10 days and were accepted as biliary fistulae. Stepwise logistic regression identified cyst con tent was the only risk factor for biliary fistulae (19% vs. 2%; P = 0.036). Described risk factors for post operative biliary complications after hydatid liver surgery may be the guidelines for additional pre-opera tive or intra-operative radiological interventions of the biliary tract and for preventive procedures such as surgical biliary drainage. Preliminary results of this study were presented at the Tenth Anniversary of Eurosurgery, Istanbul, Turkey, June 20–24, 2000.     

In Vivo Healing Effects of Ankaferd Blood Stopper on the Residual Pancreatic Tissue in a Swine Model of Distal Pancreatectomy

The aim of this study was to determine whether intraoperative Ankaferd blood stopper (ABS) application into the pancreatic channel and to the pancreatic remnant surface following distal pancreatectomy can or cannot prevent postoperative pancreatic fistula formation. Three pigs underwent distal pancreatectomy under general anesthesia. In two of the pigs, 0.5 ml of ABS was applied to the stump surface area after adding 0.5 ml of ABS into the pancreatic channel. The remaining one animal served as the control. The pigs were sacrificed on the seventh postoperative day for autopsy. The pancreatic remnants from the animals were then taken for histopathological analyses. It was observed that the oral intake had been broken and abdominal distention had developed in the control pig following on the third postoperative day. However, no significant clinical changes were observed in the ABS-applied pigs. In the autopsy, it was found that the control pig had generalized peritonitis with pancreatic necrosis. On the other hand, the ABS-applied pigs had either macroscopically and microscopically normal pancreatic tissue architecture with an occluded Wirsung duct at the pancreatic stump. It was concluded that application of ABS on the transected surface and into the pancreatic channel could prevent pancreatic fistula formation and improve wound healing in the residual pancreatic tissue following distal pancreatectomy.     

Cost of renal replacement therapy in Turkey

BACKGROUND AND RESULTS: By the end 2000, 22224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US dollars 22759 for haemodialysis (HD), US dollars 22350 for continuous ambulatory peritoneal dialysis (CAPD), and US dollars 23393 and US dollars 10028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US dollars 488958709, which corresponds to nearly 5.5% of Turkey's total health expenditure. CONCLUSION: Measures such as early construction of vascular access, promoting home dialysis and the reuse of the dialysers, strict control of the use of some expensive drugs like erythropoietin and active vitamin D, and also increasing the number of transplantations, especially if pre-emptive transplantation is possible, should be taken into account in order to reduce these expenses.     

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Sir, Garthwaite et al. report a rare case of squamous cell carcinomaof the bronchus associated with AA (secondary) amyloidosis.In