N Bilgin

The use of silver nitrate-incorporated amniotic membrane as a temporary dressing☆

Human amniotic membrane is one of the most effective biological dressings used in burn treatment. Since 1978, we have been using human amniotic membrane incorporating 0.5 per cent silver nitrate. Studies in 96 patients using this method showed that the silver-incorporated membranes gave a better therapeutic effect than plain amniotic membranes. It was noted that 0.5 per cent silver nitrate incorporated into the membranes increased their manageability, provided easier application to the burned area and created a bactericidal effect, therefore reducing the risk of contamination and infection. One of the main advantages of wound coverage with amniotic membrane is that it does not appear to discourage re-epithelization, reduces fluid, protein, heat and energy loss, increases mobility and most important this may be the ideal wound cover next to the patients own skin. Therefore, we highly recommend the use of 0.5 per cent silver nitrate-incorporated amniotic membrane, since it is readily available and freely obtainable, has low preparation and storage costs that make it an ideal dressing to use, especially in countries where economic factors prevent the purchase of other types of dressings.

Epidemiological survey of burns treated in Ankara, Turkey and desirable burn-prevention strategies

From 1 January 1979 to 31 December 1993, 1109 patients were admitted to our burn unit located at Hacettepe University. Of the patients, 638 (57.5 per cent) were children (under the age of 16 years). The male to female ratio was 1.4:1 in children, and was approximately 2.6:1 for patients over 16 years of age. Of the 638 paediatric patients, 67 (10.5 per cent) sustained electrical burns. The causes of injury in the remaining 571 cases (89.5 per cent) were hot liquids in 379 (66.4 per cent of the non-electrical burns), flame in 190 (33.3 per cent) and contact burns in two (0.3 per cent). Of the scalds, 296 (78.1 per cent of the scalds), 52 (13.7 per cent), 22 (5.8 per cent) and nine (2.4 per cent) were caused by hot water, milk, meal and oil respectively. Of the flame burns, 21 (11.1 per cent) were due to LPG explosions. Of the 471 adult patients (over 16 years), 159 (33.8 per cent) were injured by electricity. The causes of non-electrical burn injuries were: hot liquid in 25, flame in 274, chemical agents in four, contact in four, and other causes in four. Although our centre is located in Central Anatolia, 41.8 per cent of all patients were referred from the other six regions of Turkey. Of the 1109 inpatients, 645 (58.2 per cent) were injured in Central Anatolia, 279 (25.2 per cent) in the Black Sea Region, 55 (5.0 per cent) in the Mediterranean Region, 18 (1.6 per cent) in the Marmara Region, 34 (3.1 per cent) in the Aegean Region, 52 (4.7 per cent) in Southeastern Anatolia and 26 (2.3 per cent) in Eastern Anatolia. Approximately two-thirds of the patients (419) required one or more surgical interventions, including debridement and grafting, as well as amputation. The most important early complications were acute renal failure (148 patients - 13.3 per cent), sepsis (660 patients - 59.5 per cent) and gastrointestinal haemorrhage (seven patients - 0.6 per cent). The overall mortality rate was 34.4 per cent. The epidemiological pattern of the burns showed that emergency measures should be taken to prevent scalding accidents to children throughout the country, and for electrical burns in adults, particularly those living in the Black Sea Region. In establishing, implementing and directing prevention programmes, regional differences should be taken into consideration.

Epidemiology of adults' and childrens' burns in a Turkish burn center.

From 1 January 1979 to 1 January 1985, 4094 patients were treated for burn injury in our centre. Of these, 84.9 per cent were treated as outpatients and 617 (15.1 per cent) were hospitalized. Of the 617 patients, 56.7 per cent were under 15 years of age (birth to 6 years: 67.7 per cent; 7-15 years, 32.3 per cent) and 43.3 per cent were over 15 years. The causes of burns in the over 15 years group were: flame, 36.3 per cent; electrical, 28.0 per cent; scalding, 18.4 per cent; liquefied petroleum (LP) gas explosion, 11.0 per cent; and others, 6.3 per cent. The burn cases in the under 15 years group were: scalding, 58.0 per cent; flame, 24.6 per cent; electrical, 10.0 per cent; hot meals, 5.2 per cent; and others, 2.0 per cent. After being resuscitated, these patients were treated with systemic antibiotics, local chemotherapy and silver-nitrate-incorporated amniotic membrane. Despite all medical efforts, 217 (35.7 per cent) of the hospitalized patients died as a result of various complications. At the same time, 3477 patients were treated as outpatients: 72.0 per cent of these were under 15 years old (birth to 6 years, 82.9 per cent, 7-15 years, 18.8 per cent) and 28.0 per cent patients were over 15 years of age. The causes of burn injury in these patients were: hot liquids, 61.7 per cent; flame, 17.0 per cent; hot meals, 8.4 per cent; hot metal, 5.8 per cent; electrical, 3.6 per cent; and chemical, 1.7 per cent.

The effect of metoclopramide on gastric emptying in traumatic brain injury.

OBJECTIVE Gastric paresis in traumatic brain injury (TBI) hinders the effectiveness of enteral support in this patient group. In this study we have investigated the effect of metoclopramide on gastric emptying in TBI patients. METHOD In this prospective, randomized, controlled, double-blind study, 19 TBI patients with Glasgow Coma Scale scores of 3-11 were included. In all patients, enteral nutrition was commenced with a nasogastric feeding tube within 48 hours of trauma. Patients were randomized into two groups. In the metoclopramide (M) group, 10 mg metoclopramide was delivered intravenously three times daily for 5 days. In the control (C) group, an equal volume of saline was administered. Besides demographics, gastric emptying according to a paracetamol absorption test at days 0 and 5, time to reach target nutritional requirements, gastric residues, intolerance to feeding, nutritional complications, and clinical outcomes were recorded for each patient. RESULTS The gastric residue rates were 2.7+/-7.4 mL and 8.1+/-17.7 mL per 100 patient days for groups C and M respectively (p=0.408). Similarly, feeding intolerance and complication rates did not significantly differ between groups C and M, (respectively p=0.543 and 0.930). Gastric emptying parameters also were similar between the study groups. CONCLUSION We were unable to document any advantage to using metoclopramide in TBI patients. Simple intragastric enteral feeding with close monitoring of the possible complications seems to be sufficient with acceptable morbidity rates.

Visceral injuries, wound infection and sepsis following electrical injuries

Visceral injuries, wound infection and sepsis were investigated in 226 inpatients who sustained electrical burns over a period of 15 years. Four patients who sustained thoracic and abdominal organ injuries were noted in this series. The patients had injuries of the small intestine, stomach, colon and the lung. All the patients received operative treatment. Two of them died of sepsis. Injuries to the internal organs should always be considered following high-voltage injuries, and they should be managed as early as possible. The data concerning wound infection and sepsis following electrical injuries were evaluated in three consecutive 5-year periods. Over this period of 15 years, different antibiotic regimens were used for prophylaxis and treatment. Most patients in the current series had been contaminated or infected by various pathogens prior to admission. Long-lasting administration of prophylactic antibiotics in these patients showed no improvement in controlling the sepsis. After 1987, most of the microorganisms were eliminated following more effective antimicrobial therapy. The progressive decrease in infection frequency of species such as Pseudomonas aeruginosa, Proteus mirabilis and Enterobacter cloacae, appeared to be causally related to the changes in the general therapeutic protocol which included new antibiotics. The infections caused by E. coli and Staphylococcus aureus showed a rather steady state. A marked increase in frequency of negative wound cultures was also noted between the years 1989 and 1993. A gradual decrease in mortality rates was observed from the first to the last 5-year period, whereas mortality rates due to sepsis showed a gradual but slower decline. Sepsis (142 patients comprising 62.8 per cent of the total mortality rate) was the most frequent complication resulting in death.

The effects of vitamin E on immune regulation after thermal injury

Studies were conducted on four groups of rats, each group consisting of 10 rats with burn + vitamin E, burn + saline solution, control + vitamin E and control + saline solution. Before and after burning 250 mg (2 cm3) of vitamin E was given intramuscularly. On the same days 2 cm3 of saline solution was given to the controls. The rats were burned over 30 per cent of their body surface area and then inoculated intraperitoneally with 40 units of tetanus toxoid. Complement fixation and acid phosphatase tests were carried out on the days 15 and 21 postburn. On day 21, the rats were killed and the spleens removed and weighted. In the groups that received vitamin E, the spleen weight and complement fixation test increased significantly while the acid phosphatase in serum decreased. In the clinical study, 17 burned patients with over 20 per cent deep partial or full skin thickness burns and eight healthy persons were studied. Nine of the 17 burned patients received vitamin E on 3 consecutive days, on day 4 blood was taken for analysis. The results showed that the number of T-cells decreased significantly in burn patients (P less than 0.05) whereas they increased significantly (P less than 0.05) in burn patients who received vitamin E. It is concluded from these experimental and clinical studies that vitamin E stimulates both cellular and humoral immunity. Therefore, the use of vitamin E in combination with conventional therapy in burn patients can be recommended.

Pediatric renal transplantation in Turkey: a review of 56 cases from a single center.

Abstract: In order to assess certain aspects of pediatric kidney transplantation (Tx) in Turkey, we retrospectively analyzed the results of 56 of these pediatric procedures performed at our center. From January 1986 to January 1998, 56 pediatric renal Tx (29 males, 27 females; 0–17 yr of age) were carried out at Başkent University Hospital. All were first‐time Tx. Fifty‐one (91%) patients were on hemodialysis and four (7.3%) were on peritoneal dialysis prior to Tx. Pre‐emptive Tx was performed for only one patient. Living‐related donors (LRD) provided 47 (84%) of the transplanted organs and cadaver sources were utilized for nine (16%) patients. The mean cold ischemia time (CIT) for cadaveric donors (CD) was 38.6 h (range 23–56 h). Among living‐related graft (LRG) recipients, the average waiting time for Tx was 4 months for Tx performed after 1990 and 8 months for those prior to 1990 (p< 0.05). Median length of hospital stay for Tx was 17±1.1 and 18±1.4 days for LRG and cadaveric graft (CG) recipients, respectively. Fifteen of 47 (33%) LRG recipients and six of nine (67%) CG recipients received anti‐rejection treatment within 30 days following the Tx surgery. Graft failure developed in 16 (12 LRG, four CG) recipients. Two patients developed Kaposis sarcoma, 17 and 3 months after Tx. There were total of six deaths (four with functioning grafts). The 1‐, 3‐, and 5‐yr graft survival rates were 93%, 75%, and 63%, respectively, and corresponding patient survival rates were 96%, 92%, and 77%. The social and educational status of 27 patients with functioning grafts were also evaluated. Our results showed that 56% of patients ended their education before high school and only three patients have been married. The high rate of school drop‐out and unemployment among pediatric renal transplant recipients in our population underline the need for a more intensive rehabilitation program.

Multiple-artery anastomosis in kidney transplantation.

KIDNEY transplantation is a form of renal replacement treatment that offers the patient a more productive and comfortable life. It is no surprise that the demand for this procedure is constantly increasing. Unfortunately, although the need for renal transplantation is growing, organ shortage remains a critical limiting factor. Over the past three decades, graft and patient outcomes have improved significantly as a result of standardization of surgical technique and refinements in immunosuppressive therapy, organ preservation, and antimicrobial therapy. Although kidney grafts with multiple renal arteries have been associated with a higher incidence of vascular and urologic complications, there is increasing pressure to use such kidneys and thus expand the potential donor pool. Multiple renal arteries occur unilaterally and bilaterally in 23% and 10% of the population, respectively, so it would clearly be in the best interests of patients to include these individuals as organ donor candidates. The effect of more than one arterial anastomosis on graft and patient survival has not been clearly defined. Our aim in this study was to measure the prevalence of multipleartery renal transplants, and to calculate the rates of acute tubular necrosis and vascular and urologic complications in recipients of these grafts. We also compared the graft and patient survival rates for patients who underwent singleversus multiple-artery anastomosis.

Severe electrical injury

From January 1979 to January 1987, 125 patients were treated in our Centre for various electrical injuries. Among them, 85 patients were over 15 years of age (89.4 per cent were males and 10.6 per cent females) and 40 patients were below 15 years of age (92.5 per cent were males and 7.5 per cent females). Electricians were the most frequently injured in the over 15-year-old age-group, whereas most patients under 15 years old were students. We focused our study on five patients with multiple and severe electrical injury. Two of these patients were injured while erecting TV aerials, two were injured at work and the other one was working on a house roof. Despite all our efforts extensive limb amputations were required. Following complete healing, we fitted prostheses to the amputation stumps. All the patients have now returned to society as capable individuals, two of them to their previous occupations and the other three with new occupations. Our experience with five patients showed that patients with severe electrical injury and multiple amputations have a reasonable chance of recovery. Rehabilitation therapy must be given as early as possible after the electrical injury so that the patients may return to their normal place in society.

A focus on health care professionals in organ donation: A cross-sectional survey

OVER THE PAST 25 years, a great deal of effort has been concentrated on increasing public awareness about transplantation and organ donation in Turkey. Unfortunately, however, the knowledge, skills, attitudes, and concerns of health care professionals (HCPs) have often been given minimal consideration, or even neglected. It is a well-known fact that HCPs, particularly those doctors and nurses who work mainly in the critical-care areas of a hospital, are key elements in the process of cadaver-organ donation. A recent survey undertaken by Evanisko et al revealed that two thirds of critical-care staff members lack the necessary training in this delicate area. This and other studies have also underscored the significant relationship between training of hospital staff and organ donation rates. We were unable to gauge the effect that such training programs have on performance measures in cadaver donations across the country; however, we designed a cross-sectional survey to assess the knowledge, attitudes, and behavior pertaining to cadaver-organ donation and transplantation in a group of doctors and nurses at five separate institutions in three Turkish cities.