Niyazi Gormus

Chest trauma in children

OBJECTIVES Chest trauma in childhood is uncommon in clinical practice. The management and treatment principles of children with thoracic trauma were discussed with the data reported in the literature. METHODS Of the chest injury diagnosed in 1653 patients, 225 were children in the last 17-year period. There were 199 boys (88.44%) and 26 girls (11.55%). The most common causes were blunt injuries in 135 cases (60%), stab wounds in 67 cases (29.77%) and gunshot wounds in 22 cases (9.77%). RESULTS Out of 225, 217 patients were treated conservatively and eight patients were treated surgically. There was no mortality and morbidity. CONCLUSIONS The prevalence of chest trauma in children due to blunt injuries is high in Turkey. Extremity injury is thought to be the most commonly associated extra-thoracic injury. However, thoracic trauma in children can be managed conservatively in most of the cases.

Epidural emphysema associated with primary spontaneous pneumothorax.

A 21-year-old male patient was admitted with spontaneous pneumothorax, and no history of asthma. Closed drainage treatment was unsuccessful. Chest computed tomography demonstrated pneumomediastinum and subcutaneous emphysema with multiple air bubbles within the spinal canal between the levels Th3 and Th11. Resection of bullae on the upper lobe and partial pleurectomy were performed. Postoperative period was uneventful. Epidural emphysema was resolved spontaneously without neurologic symptoms and signs. Intraspinal air, or pneumorachis, associated with spontaneous pneumothorax and pneumomediastinum is an extremely rare condition. We discussed spontaneous pneumothorax and pneumomediastinum as well as epidural pneumatosis and reviewed reported cases in the literature.

Methylprednisolone prevents inflammatory reaction occurring during cardiopulmonary bypass: effects on TNF-α, IL-6, IL-8, IL-10:

Objective: This study examined the correlation between tumour necrosis factor-alfa (TNF-α), interleukin (IL)-6 and IL-8, IL-10 and methylprednisolone pretreatment. Methods: This is a prospective, randomized and double-blinded study. Sixty patients undergoing coronary artery bypass grafting (CABG) were randomized to receive either intravenous methylprednisolone (n=30, Group M) or intravenous placebo (n=30, Group S). The patients received intravenously either 30 mg/kg methylprednisolone (Group M) or placebo (Group S) 10 min before and after cardiopulmonary bypass (CPB). In an intensive care unit (ICU), four additional doses were given at 6-hourly intervals. Blood samples for the measurements of TNF-α, IL-6, IL-8 and IL-10 were obtained before induction of anaesthesia (T0=control value), after induction (T1), before starting CPB (T2), after aortic declamping (T3), at the end of CPB (T4) and 6 hours (T5), 12 hours (T6) and 24 hours (T7) after skin closure. Creatine kinase (CK) and creatine kinase isoenzyme MB (CK-MB) were evaluated at the following intervals: T0, T5, T6 and T7. Results: When compared with the control value, TNF-α, IL-6 and IL-8 significantly increased in Group S and Group M (p B-0.05), but these values were significantly greater in Group S than in Group M (p B-0.05). In comparison with the control value, IL-10 increased in both groups (p B-0.05), but was significantly greater in Group M than in Group S (p B-0.05). CK and CK-MB were increased in both groups in postoperative values compared to control values. In Group S, CK and CK-MB levels were significantly lower than in Group M (p B-0.05). Conclusion: In this study, we have found that pre-operative administration of methylprednisolone has decreased TNF-α, IL-6 and IL-8 release, and increased the perfusing IL-10 levels after CPB. Thus, methylpredniso-lone may decrease the inflammatory response during the CPB procedure.

The clinical and surgical features of right-sided intracardiac masses due to echinococcosis.

Right-sided cardiac echinococcosis shows special clinical and surgical features beyond the rareness of echinococcosis in this position, leading to serious and life-threatening complications. We examined our cardiac hydatid cyst patients, retrospectively, and report our experience of the surgical treatment of right-sided cardiac hydatid cysts. Between 1985 and 2000, seven patients were transferred to our department from the cardiology department with a diagnosis of cystic cardiac masses which were highly suspected of being hydatid cysts. Two were males and 5 were females. In 3 patients the hydatid cyst was located in the right ventricle, and one was in the right atrium. The mean age of the patients was 37 years (ranging from 12 to 60 years). One patient had preoperative pulmonary emboli. In all right-sided cardiac echinococcosis patients, cardiopulmonary bypass was used. All cysts were cleaned after quilting the cystic cavities, and daughter cysts were removed carefully. The cavities were closed with purse-string sutures. Postoperatively, one patient had pulmonary emboli. In all patients, mebendazole was administered postoperatively. When a right-sided cardiac hydatid cyst is diagnosed, early surgical treatment should be performed under open-heart surgery conditions. During the operation, a single cannula in the superior vena cava should be used until fibrillation, and after clamping, the cannula for the pulmonary artery inferior vena cava should be inserted.

Pulmonary embolism due to cardiac hydatid disease: imaging findings of unusual complication of hydatid cyst

Abstract. We report two cases of primary cardiac hydatid cyst in which hydatid materials caused recurrent embolizations in pulmonary arteries and pulmonary parenchyma. Cardiac hydatid cysts may stay asymptomatic for a long time, until they reveal themselves being perforated into cardiac chambers and/or pulmonary artery or systemic circulation. The role of imaging techniques in diagnosis is discussed and the importance of dynamic enhanced CT, MR imaging, and enhanced MR angiography (MRA) is reported. Imaging findings were confirmed by surgery and pathology. Early diagnosis is essential because delayed treatment increases the morbidity and mortality rates.

Effect of off-pump and on-pump coronary artery bypass grafting on renal function.

Background. Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) has the risk of renal dysfunction. The cause of renal dysfunction after CPB is multifactorial, such as nonpulsatile flow, renal hypoperfusion, hypothermia, and duration of CPB. This study compared off-pump technique with on-pump technique on renal function in patients who underwent CABG. Methods. Sixty patients with normal preoperative renal functions undergoing CABG were randomly assigned to conventional revascularization with CPB (on-pump) or beating heart revascularization (off-pump). Renal functions were assessed up to 10 days postoperatively. Results. Creatinine clearance was found to be significantly higher in the off-pump group than in the on-pump group (p < .05). The off-pump group had significantly less increase in creatinine levels when compared with the on-pump group (p < .05). The free water clearance values decreased similarly in both groups; however, the recovery was more prompt in the off-pump group (p < .05). No significant differences were found in the prevalence of postoperative hemodialysis. Conclusion. The off-pump technique may provide a positive contribution and sufficient protection on postoperative renal functions in patients undergoing CABG.

Cold abscess of the chest wall as an unusual complication of BCG vaccination

Bacillus-Calmette-Guérin (BCG) vaccination often results in local adverse effects; however, serious or long-term complications are rare. The involvement of sternum among skeletal BCG osteomyelitis is a rarely seen complication of BCG vaccination. Such a complication may confuse with a chest wall tumor and a surgical intervention may be needed for the definite diagnosis. A 9-month-old infant who had a parasternal cold abscess in the anterior chest wall and sternal osteomyelitis of tuberculosis in the late period of BCG vaccination of whom the etiological diagnosis was histopathologically confirmed after surgery is presented and the preoperative diagnostic problems are discussed.

Clinical features and surgical treatment of cardiac myxoma: report of 18 cases.

Myxomas are the most common benign primary cardiac tumors. As many patients with cardiac myxoma suffer from cerebral or systemic embolism, which are serious complications, diagnosis of the tumor is vital. Between 1990 and 2000, 18 patients (6 males, 12 females), aged 24 to 73 years (mean, 55.3 years), were operated on for cardiac myxoma. The most common location of the myxoma was the left atrium (78%), and the transseptal surgical approach was preferred (78%) as it allows total resection of the left atrial myxoma along with its pedicle. Carney complex, a familial autosomal dominant form of atrial myxoma, was not found in any of the patients. There had been no operative or postoperative mortality and morbidity. The mean postoperative follow-up period was 5 years (mean, 1 to 10 years). No recurrence had been seen. We believe that the transseptal approach, in allowing total resection of the myxoma, prevents recurrence.

Preconditioning with levosimendan prevents contractile dysfunction due to H2O2-induced oxidative stress in human myocardium.

We studied the inotropic and possible antioxidant effects of levosimendan in human atrial strips, before and after induction of oxidative stress induced by H2O2. Levosimendan (10−9 to 10−6 M) increased contractions induced by electrical stimulation (ES) in human atrial strips. The maximal positive inotropic effect of levosimendan was 145.6 ± 4.6% of predrug values. H2O2 (10−6 to 10−3 M) significantly reduced contractions induced by ES. The maximum inhibition by H2O2 on the ES induced contraction was 47.2 ± 3.5%. Levosimendan significantly increased the isometric contractions induced by ES when compared with the values obtained in the presence of 10−5 M H2O2 by 89.0 ± 4.7%, 98.9 ± 3.4%, and 111.2 ± 3.7% at 10−8, 10−7, and 10−6 M concentrations, respectively. In concentrations of 10−7 and 10−6 M levosimendan, the maximum responses to ES increased when compared with the values obtained in the presence of 10−3 M H2O2 by 87.1 ± 3.6% and 95.1 ± 5.3%, respectively. The cumulatively applied H2O2 (10−6-10−3 M) did not change the positive inotropic response to levosimendan. In conclusion, levosimendan reverses the myocardial dysfunction induced by oxidative stress in human right atrial strips. Levosimendan prevents myocardial dysfunction if administered before oxidative stress.

Serum uric acid may predict development of progressive acute kidney injury after open heart surgery

Abstract Objectives: Acute kidney injury (AKI) is a common complication of cardiac surgery developing in 25–35% cases. Recently, neutrophil gelatinase-associated lipocalin (NGAL) was shown to predict AKI development earlier than serum creatinine. Some studies demonstrated the predictive role of post-operative serum uric acid (SUA) as an early marker of AKI. We aimed to study the role of serum and urine NGAL as well as SUA to predict progression of AKI. Design and methods: This is a prospective observational study of patients undergoing cardiac surgery. Blood and urine samples for measurement of uric acid, serum and urine NGAL levels were collected prior to cardiac surgery (0 h), and in the time course at 2nd and 24th hours after surgery. Patients who developed AKI were divided into two subgroups as progressing and non-progressing AKI. Results: Sixty patients (42 males, 18 females) were included. After cardiac surgery, 40 patients developed AKI, 20 of whom non-progressing AKI, and 20 progressing AKI. All of the markers significantly increased in AKI patients. A receiver operator characteristics (ROC) curve analysis showed higher predictive ability of SUA for progressing AKI compared with serum and urine NGAL. When compared markers obtained at the second hour after surgery, UA had significantly large AUC than NGAL to predict AKI developed at 24 and 48 h, particularly in patients, who require renal replacement therapy (RRT). Conclusion: Uric acid seems to predict the progression of AKI and RRT requirement in patients underwent cardiac surgery better than NGAL.