Sonographic diagnosis of choledochocele

We present a case of a 48-year-old female with a history of cholecystectomy and recurrent attacks of pancreatitis whose initial abdominal sonography (US) revealed multiple conglomerated stones in the descending part of the duodenum. Abdominal CT, MRI, and magnetic resonance cholangiopancreatography showed the same findings. The distended sacciform distal intramural segment of the common bile duct was protruding into the duodenum. The imaging findings explained the etiology of the patient's recurrent attacks of pancreatitis and led to surgical excision of the choledococele.     

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.     

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.     

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.     

Comparison of MRI and renal cortical scintigraphy findings in childhood acute pyelonephritis: preliminary experience

OBJECTIVE: The diagnosis of acute pyelonephritis in children remains a clinical challenge. It may cause permanent renal scar formation and results in the chronic renal failure if prompt diagnosis and treatment are delayed. The purpose of this study is to compare magnetic resonance imaging (MRI) and renal cortical scintigraphy (RCS) findings in childhood acute pyelonephritis and to determine pyelonephritic foci in the acute phase. MATERIALS AND METHOD: Twenty children (15 females and five males) with symptoms dysuria, enuresis, costovertebral pain, fever of 37.5 degrees C or more and/or positive urine culture were imaged by unenhanced turbo spin echo T2, spin echo T1-weighted, pre- and post-gadolinium inversion recovery MRI and RCS. Both imaging techniques were read independently by two radiologists and nuclear medicine specialists. Sensitivity and specificity of MRI in detecting acute pyelonephritic foci and scar lesions were calculated. Furthermore, in order to calculate the reliability of MRI over RCS in differentiating scar tissue and acute pyelonephritic foci, follow-up MRI studies were done in six patients after treatment of acute pyelonephritis. RESULTS: Sensitivity and specificity of MRI in the detection of pyelonephritic lesions were found to be 90.9 and 88.8%, respectively. There is no statistically significant difference in lesion detection between the two diagnostic modalities (P>0.05). CONCLUSION: Post-gadolinium MR images show significant correlation with RCS in the determination of renal pathology. Moreover, the ability of discriminating acute pyelonephritic foci and renal scar in early stages of disease is the superiority of MRI.     

Comparison of a 4.5?F semi-rigid ureteroscope with a 7.5?F rigid ureteroscope in the treatment of ureteral stones in preschool-age children

The aim of this study was to compare the success and complication rates of a 4.5?F ureteroscope with a 7.5?F ureteroscope in the treatment of urolithiasis in preschool-age children. We retrospectively reviewed 69 ureteroscopy (URS) procedures in a pediatric population (40 boys, 29 girls). We divided the patients into two groups according to the type of ureteroscope used: group 1 (n?=?42, Storz 7.5?F) and group 2 (n?=?27, Wolf 4.5?F). We statistically compared all the procedures performed in both groups regarding patient age, complication rates, whether the procedure was therapeutic, and whether we used a guidewire. Additionally, in cases with ureteral stones, we also compared the stone clearance rate and the necessity of X-ray imaging between the two groups. The mean patient age was 56.04 months in group 1 and 47.48?months in group 2 (p?=?0.057). The stone-free rate was 78.6?% in group 1 and 92.6?% in group 2 (p?>?0.05). However, when we compared the stone-free rates for patients younger than 3 years, the rate was 66.7?% in group 1 and 93.8?% in group 2 (p?<?0.05). The difference was not statistically significant for patients between the ages of 4 and 7?years. The success and failure rates revealed better outcomes for treatment of ureteral stones with a 4.5?F ureteroscope. We recommend the use of the mini-ureteroscope, especially in infants and preschool-age children.     

Can ultrasonography-guided aspiration and steroid injection treat reflux venous blood flow around symptomatic Baker’s cysts? Our short-term experience

Objective

The aim of the current study was to investigate the efficacy of ultrasonography-guided aspiration treatment with concomitant steroid injection on relieving reflux blood flow in veins located next to symptomatic Baker’s cyst.

Methods

All patients were examined by ultrasonography at administration and 1 month follow-up after intervention. Puncture and aspiration of the cyst, as well as injection of 1 ml dexamethasone were performed by the same radiologist. Compression on popliteal vein and vena saphena parva and the degrees of reflux before and after treatment were recorded.

Results

Twenty-six patients were included in the study. An overall reduction of the cyst’s size was observed in all patients of the study group. Reduction of the cyst size is more evident during the 1st week, which was observed by a slight enlargement during the 1st and the 3rd months controls.

Conclusion

Ultrasonography-guided puncture, aspiration and steroid injection seems to yield promising outcomes in terms of relieving venous reflux flow around simple Baker’s cysts.

     

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

N^G-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.