Ali Konan

A New Model for Tethered Cord Syndrome: A Biochemical, Electrophysiological, and Electron Microscopic Study

In order to investigate the pathophysiology of the tethered cord syndrome, a few experimental models have been developed and used previously. In this study, the authors present a new experimental model to investigate the biochemical, electrophysiological, and histopathological changes in the tethered spinal cord syndrome. A model was produced in guinea pigs using an application of cyanoacrylate to fixate the filum terminale and the surrounding tissue to the dorsal aspect of the sacrum following 5-gram stretching of the spinal cord. The experiments were performed on 40 animals divided into two groups. The responses to tethering were evaluated with hypoxanthine and lipid peroxidation, somatosensory and motor evoked potentials, and transmission electron microscope examination. The hypoxanthine and lipid peroxidation levels significantly increased, indicating an ischemic injury (p < 0.01). The average hypoxanthine level in the control group was 478.8 +/- 68.8 nmol/g wet tissue, while it was 651.2 +/- 71.5 nmol/g in the tethered cord group. The lipid peroxidation level in group I was 64.0 +/- 5.7 nmol/g wet tissue, whereas it was 84.0 +/- 4.7 nmol/g in group II. In the tethered cord group, the latencies of the somatosensory and motor evoked potentials significantly increased, and the amplitudes decreased. These changes indicated a defective conduction in the motor and sensorial nerve fibers. In the transmission electron microscopic examinations, besides the reversible changes like edema and destruction in the gray-white matter junction, irreversible changes like scarcity of neurofilaments and destruction in axons and damage in myelin sheaths were observed. We consider that this work can be used as an experimental model for tethered cord syndrome.

Combined Long-Term Steroid and Immunosuppressive Treatment Regimen in Granulomatous Mastitis

Background: Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It is related to various etiological factors. The treatment of IGM is challenging as there is a lack of consensus in the literature and treatment options vary widely. Conservative treatment with antibiotics, glucocorticoids and immunosuppressive drugs, and surgery are used in the management of the disease. In this article we report our experience with IGM patients receiving immunosuppressive treatment. Patients and Methods: The medical records of patients with IGM receiving systemic therapy at the Hacettepe University Hospital between October 2007 and May 2010 were reviewed. 15 cases of histopathologically proven IGM were identified. The data was examined for risk factors and success of treatment. Results: 14 patients were given prednisolone together with azathioprine, and 1 patient who was pregnant at the time of diagnosis received only prednisolone (30 mg/day). 11 (73%) patients had a complete response to systemic therapy. 2 patients had a relapse, of whom 1 required surgical drainage and 1 was treated with a higher dose of glucocorticoids. Conclusion: Systemic therapy is a safe and effective treatment for IGM. The addition of azathioprine to glucocorticoid therapy permits quick tapering of the steroid doses and increases the treatment success.

The Effect of Problem-Based Learning With Cooperative-Learning Strategies in Surgery Clerkships

BACKGROUND Cooperative learning is used often as part of the problem-based learning (PBL) process. But PBL does not demand that students work together until all individuals master the material or share the rewards for their work together. OBJECTIVE A cooperative learning and assessment structure was introduced in a PBL course in 10-week surgery clerkship, and the difference was evaluated between this method and conventional PBL in an acute abdominal pain module. METHODS An experimental design was used. RESULTS No significant differences in achievement were found between the study and control group. Both the study and control group students who scored low on the pretest made the greatest gains at the end of the education. Students in the cooperative learning group felt that cooperation helped them learn, it was fun to study and expressed satisfaction, but they complained about the amount of time the groups had to work together, difficulties of group work, and noise during the sessions. CONCLUSIONS This study evaluated the impact of a cooperative learning technique (student team learning [STL]) in PBL and found no differences. The study confirms that a relationship exists between allocated study time and achievement, and students satisfaction about using this technique.

Simultaneous forequarter amputation and radical mastectomy for metastatic breast carcinoma in a male patient: a case report

Although the majority of forequarter amputations are performed for high-grade bone and soft tissue sarcomas or extensive osteomyelitis of the upper extremity, this radical operation may also be indicated for the curative treatment of recurrent breast cancer and for the palliation of locally advanced breast cancer. We report a male patient with metastatic breast adenocarcinoma who underwent simultaneous mastectomy and forequarter amputation for the management of both his primary and metastatic disease.

Resuscitation and monitoring in gastrointestinal bleeding

IntroductionGastrointestinal bleeding is a common life-threatening problem, causing significant mortality, costs and resource allocation. Its management requires a dynamic multidisciplinary approach that directs diagnostic and therapeutic priorities appropriately.Materials and methodsArticles published within the past 15 years, related to gastrointestinal bleeding, were reviewed through MEDLINE search, in addition to current guidelines and standards.ResultsDecisions of ICU admission and blood transfusion must be individualized based on the extent of bleeding, hemodynamic profile and comorbidities of the patient and the risk of rebleeding. A secure airway may be required to optimize oxygenation and to prevent aspiration. Doses of induction agents must be reduced due to the changes in volume of distribution. Volume replacement is the cornerstone of resuscitation in profuse bleeding, but nontargeted aggressive fluid resuscitation must be avoided to allow clot formation and to prevent increased bleeding. Decision to give blood transfusion must be based on physiologic triggers rather than a fixed level of hemoglobin. Coagulopathy must be corrected and hypothermia avoided. Need for massive transfusion must be recognized as early as possible, and a 1:1:1 ratio of packed red blood cells, fresh frozen plasma and platelets is recommended to prevent dilutional coagulopathy. Tromboelastography can be used to direct hemostatic resuscitation. Transfusion related lung injury (TRALI) is a significant problem with a mortality rate approaching 40%. Prevention of TRALI is important in patients with gastrointestinal bleeding, especially among patients having end-stage liver disease. Preventive strategies include prestorage leukoreduction, use of male-only or never-pregnant donors and avoidance of long storage times. Management of gastrointestinal bleeding requires delicately tailoring resuscitation to patient needs to avoid nonspecific aggressive resuscitation. “Functional hemodynamic monitoring” requires recognition of indications and limitations of hemodynamic measurements. Dynamic indices like systolic pressure variation are more reliable predictors of volume responsiveness. Noninvasive methods of hemodynamic monitoring and cardiac output measurement need further verification in patients with gastrointestinal bleeding.ConclusionsManagement of gastrointestinal bleeding requires a dynamic multidisciplinary approach. The mentioned advances in management of hemorrhagic shock must be considered in resuscitation and monitoring of patients with GI bleeding.

Improvement in Treatment Efficacy in Patients Admitted to the Hacettepe University Burn Unit-33 Years of Experience

Yazışma Adresi / Address for Correspondence: Dr. Kaya Yorgancı, e.posta: yorganci@hacettepe.edu.tr DOI: 10.5152/dcbybd.2016.1234 ©Telif Hakkı 2016 Türk Dahili ve Cerrahi Bilimler Yoğun Bakım Derneği Makale metnine www.dcyogunbakim.org web sayfasından ulaşılabilir. ©Copyright 2016 by Turkish Society of Medical and Surgical Intensive Care Medicine Available online at www.dcyogunbakim.org Objective: In the evaluation of burn patients, LA50 values are important for the determination of treatment efficacy and the demonstration of possible improvement over time. The aim of the present study was to determine the LA50 values and related parameters between January 1, 1979 and January 1, 2013.

Differential Diagnosis in Groin Pain: Perspective from the General Surgeon

Groin pain is a debilitating injury, which causes elite players to miss games, even seasons. Most of the conditions causing groin pain in athletes are of musculoskeletal origin. However, although most are rare, other causes of groin pain should be kept in mind. Groin pain may be due to pathologies of the lower rectus musculature, inguinal region, pubic symphysis, upper adductors of the thigh and scrotum. Any pain which worsens during exercise and improves during resting is most probably of muscular origin. During a physical examination, swelling that becomes more prominent with an increase of intra-abdominal pressure or valsalva maneuver may be a sign of inguinal hernia. Ultrasonography and magnetic resonance imaging sensitivities to detect occult inguinal hernias are high. Sportsman hernia describes the phenomena of chronic activity related groin pain unresponsive to conservative therapy and significantly improved with surgical repair. Patients usually return to their previous level of play within 3 months. Hockey groin syndrome is marked by small tears of the external oblique aponeurosis through which small neurovascular branches of the ilioinguinal nerve emerge. Surgical excision of entrapped nerves together with repair of the external oblique aponeurosis offers good results. Other nerve entrapment syndromes are usually due to previous abdominal surgery or trauma.

Stress Ralated Erosive Syndrome Prophylaxis in Intensive Care Units

Strese bağlı erozif sendromda ciddi kanama hastaların %06.-6’sında görülmektedir ancak bu kanamaların insidansı azalma eğilimindedir. Bunda profl aktik ilaçların yaygın kullanımı dışında kritik hastaların bakımlarında ve endoskopik tedavilerdeki gelişmeler de etkilidir. Strese bağlı erozif sendrom için iki önemli risk faktörü 48 saatten daha uzun süren entübasyon (odds oranı 15.6) ve koagülopati (odds oranı 4.3) varlığıdır. Strese bağlı erozif sendromun önlenmesi öncelikle genel tıbbi prensiplerin uygulanmasını gerektirir. Bu önlemler sıvı resüsitasyonu, sepsisin kontrolü ve uygun doku oksijenasyonunun sağlanmasıdır Profl aksi üç grupta incelenebilir. 1gastrik asidin nötralizasyonu (antasitler), 2gastrik asit sekresyonunun azaltılması (H2 reseptör blokörleri, proton pompa inhibitörleri), 3mide mukozasının güçlendirilmesi (sükralfat). Profl aksi kanama insidansını azaltmasına rağmen mortalitede bir azalmayı göstermek mümkün olmamıştır. (Yoğun Bakım Derg 2010; 2: 48-51) Anahtar sözcükler: Strese bağlı erozif sendrom, kanama, profl aksi Geliş Tarihi: 09.04.2010 Kabul Tarihi: 28.05.2010 Although the incidence is decreasing, stress-related erosive syndrome causes overt bleeding in 0.6-6% of critically ill patients. The use of prophylactic medicine and advances in the care and endoscopic treatment of the patients is responsible for this decrease. The two main factors in the development of the stress-related erosive syndrome are ventilation lasting more than 48 hours and coagulopathy. General preventive measures such as fl uid resuscitation, control of sepsis and adequate tissue oxygenation is essential to prevent stress-related erosive syndrome. Prophylaxis may be divided in tree groups: neutralization of the gastric acid (antacids), inhibition of the gastric acid secretion (H2 blockers, proton pump inhibitors) and reinforcement of the gastric mucosa (sucralfate). Although prophylaxis decreases the incidence of bleeding, a decrease in the mortality is not shown. (Yoğun Bakım Derg 2010; 2: 48-51)

Effects of Prostacyclin on Hemodynamics after Intestinal Ischemia-Reperfusion

Ten rabbits underwent 30 minutes of superior mesenteric artery occlusion to assess the release of tumor necrosis factor, subcellular damage, and hemodynamic changes after intestinal ischemia-reperfusion injury. Five were treated with prostacyclin 5 ng/kg/min 5 minutes before the arterial occlusion. It was increased to 25 ng/kg/min during occlusion, decreased to 5 ng/kg/min for the first 5 minutes of reperfusion, and then discontinued. A control group of 5 rabbits did not receive any pharmacological agent. Specimens were obtained from the small intestine for electron microscopy after 10 minutes and after 60 minutes of reperfusion, while simultaneous blood samples were collected for measurement of tumor necrosis factor. Minimal changes were seen in tissue from the prostacyclin group but severe mitochondrial damage and vacuolation occurred in the control group. The tumor necrosis factor level was 11.97 ± 3.17 U/mL in the control group and 5.06 ± 2.19 U/mL in the prostacyclin group, one hour after the end of mesenteric occlusion (p < 0.05). Hemodynamic status, assessed by central venous and arterial pressures, was much more affected in the control group than in the prostacyclin group. Mean arterial pressure was 71 ± 5 mm Hg in the control group, and 91 ± 6 mm Hg in the prostacyclin group (p < 0.05). Central venous pressure was 5.3 ± 0.9 mm Hg in the control group and 2.3 ± 0.7 mm Hg in the prostacyclin group (p < 0.05). We conclude that intravenous prostacyclin reduced the severity of reperfusion injury occurring during the early period of reperfusion by inhibiting the release of the toxic mediator tumor necrosis factor, thus decreasing distant organ injury.