Ozlem Koksal

MR imaging in the detection of diffuse axonal injury with mild traumatic brain injury

Abstract Purpose: To evaluate the occurrence and distribution of mild traumatic brain injury (MTBI) caused by diffuse axonal injury (DAI) using magnetic resonance (MR) imaging and to attempt to correlate MR findings with post-concussion symptoms (PCS). Patients and methods: Forty MTBI patients (mean age: 32.5 years) with normal cranial computed tomography (CT) findings were examined with standard MR protocol including T1-weighted, T2-weighted, fluid attenuated inversion recovery (FLAIR), gradient echo (GRE) and diffusion-weighted (DW) sequences. MR imaging was performed within 24 hours of injury. The lesions were classified as DAI based on their location and morphologic appearance. Results: In MR imaging of five (12.5%) of the patients, the lesions compatible with DAI were observed. Four patients (10%) had the foci of low signal intensity compatible with hemorrhagic shear injury on the GRE sequence, and five (12.5%) patients had high signal intensity on FLAIR and DW sequence. Conclusion: MR imaging can be helpful in revealing DAI lesions in patients with normal CT scan findings after MTBI. FLAIR, GRE and DW sequences are superior to conventional spin-echo images in detecting DAI lesions.

Childhood falls: characteristics, outcome, and comparison of the Injury Severity Score and New Injury Severity Score

Objectives: The aim of this study was to determine the general characteristics of childhood falls, factors affecting on mortality, and to compare the Injury Severity Score (ISS) and the New Injury Severity Score (NISS) as predictors of mortality and length of hospital stay in childhood falls. Methods: We retrospectively analysed over a period of 8 years children aged younger than14 years who had sustained falls and who were admitted to our emergency department. Data on the patients’ age, sex, type of fall, height fallen, arrival type, type of injuries, scoring systems, and outcome were investigated retrospectively. The ISS and NISS were calculated for each patient. Comparisons between ISS and NISS for prediction of mortality were made by receiver operating characteristic (ROC) curve and Hosmer-Lemeshow (HL) goodness of fit statistics. Results: In total, there were 2061 paediatric trauma patients. Falls comprised 36 (n = 749) of these admissions. There were 479 male and 270 female patients. The mean (SD) age was 5.01 (3.48) years, and height fallen was 3.8 (3) metres. Over half (56.6%) of patients were referred by other centres. The most common type of fall was from balconies (38.5%), and head trauma was the most common injury (50%). The overall mortality rate was 3.6%. The cut off value for both the ISS and NISS in predicting mortality was 22 (sensitivity 90.5%, specificity 95.4% for ISS; sensitivity 100%, specificity 88.7% for NISS) (p>0.05). Significant factors affecting mortality in logistic regression analysis were Glasgow Coma Scale (GCS) <9, ISS >22, and NISS >22. There were no significant differences in ROC between three scoring systems. The HL statistic showed poorer calibration (p = 0.02 v p = 0.37, respectively) of the NISS compared with the ISS. Conclusions: In our series, the head was the most frequent site of injury, and the most common type of fall was from balconies. Scores on the GCS, NISS, and ISS are significantly associated with mortality. The performance of the NISS and ISS in predicting mortality in childhood falls was similar.

Tau protein as a serum marker of brain damage in mild traumatic brain injury: Preliminary results

The objective of this study was to investigate the diagnostic value of serum tau protein in determining the severity of traumatic brain injury in patients with mild traumatic brain injury (mTBI) and high-risk patients. Adult patients who presented to our emergency department (ED) with mTBI over 1 year were prospectively enrolled. Patients underwent cranial computed tomography (CT) and were subdivided into high and low-risk groups, according to the probability of resultant intracranial injury. Serum tau levels of 60 patients and 20 healthy volunteers, who served as a control group, were measured. The mean age of the 60 patients (45 males, 15 females) was 32.5 years (range, 15–66 y). Mean Glasgow Coma Scale (GCS) score was 14±0.6. CT scans demonstrated intracranial injury in 11 patients (18.3%) and depressed fracture in 4 patients (6.7%). Serum tau levels of patients (188±210 pg/mL), compared with those of controls (86±48 pg/mL), were relatively higher; however, differences were not statistically significant (P=.445). Also, serum tau levels of high-risk patients (307±246 pg/mL) were significantly higher than those of low-risk patients (77±61 pg/mL) (P=.001). A total of 48 patients (80%) were accessible for follow-up after 6 months. Postconcussive syndrome was observed in 8 patients, 5 of whom had serum tau protein levels that were higher than those of the other 3 patients. However, no statistically significant difference was observed (P > .05). Investigators of the present study noted that serum tau levels in patients with mTBI were increased. Therefore, it is believed that this biomarker may prove helpful in identifying high-risk patients with mTBI. However, additional studies are needed to establish the diagnostic value of serum tau in detecting traumatic brain injury in patients with mTBI.

Relationships between markers of inflammation, severity of injury, and clinical outcomes in hemorrhagic shock.

This study was performed to investigate the relationships between markers of inflammation in serum (interleukin-6 [IL-6], interleukin-10 [IL-10], and granulocyte elastase [CE]), severity of injury, and clinical outcomes, and to evaluate the predictive value of these markers for major complications and mortality. This study, which was conducted between August 2003 and May 2005, examined patients older than 16 y who were admitted to the Emergency Unit of the Uludag University Medical School within 12 h after trauma, and who had traumatic hemorrhagic shock (THS) at admission. Three groups were established: the THS group (n=20), the pure hemorrhagic shock (PHS) group (n=20), and the healthy control group (n=20). Demographic data were recorded for all subjects, and blood samples were taken for lactate, base excess, CE, IL-6, and IL-10 measurements. The Glasgow Coma Score, the Revised Trauma Score, the Injury Severity Score, the New Injury Severity Score, and the Trauma Score-Injury Severity Score were calculated; complications and final clinical outcomes were monitored. A total of 35 men and 25 women were included in the study; mean patient age was 41 ±17 y. In the THS group, scores were as follows: Revised Trauma Score, 10.2±2.2; Trauma Score-Injury Severity Score, 0.86±0.2; Injury Severity Score, 24.8±9.0; and New Injury Severity Score, 32.7±9.0. IL-6, IL-10, lactate, and base excess levels in the THS group were significantly higher than those in the PHS and healthy control groups. The serum CE level of the THS group was significantly higher than that of the healthy control group, but it did not differ significantly from that of the PHS group. Complications such as sepsis, acute respiratory distress syndrome, and multiple organ failure occurred in 50% of the THS group and in 20% of the PHS group. Mortality was 30% in the THS group and 10% in the PHS group. In the THS group, no significant differences were noted between markers of inflammation and trauma scores of patients who died and those who survived. The investigators concluded that although the levels of markers of inflammation increased in THS patients, they were inadequate for predicting mortality and the development of complications such as acute respiratory distress syndrome, multiple organ failure, and sepsis. A larger study based on the use of serial marker measurements is warranted.

Hipotermi ve varfarin uygulanan şiddetli femoral arter kanamalı sıçan modelinde kitosan lineer polimer’in (Celox®) hemostatik etkinliği

BACKGROUND In this study, the hemostatic efficacy of Celox® in rats under hypothermia or warfarin treatment was investigated. METHODS A total of forty-eight Sprague-Dawley female rats weighing 200-350 g were used in the study. Six experimental study groups were designed, as follows: Group 1: Normothermia + compression; Group 2: normothermia + Celox®; Group 3: hypothermia + compression; Group 4: hypothermia + Celox®; Group 5: normothermia + warfarin + compression; and Group 6: normothermia + warfarin + Celox®. RESULTS Celox® provided effective hemorrhage control in all three tested groups. There was a statistically significant difference between compression and Celox® implementation in all groups in terms of hemostasis (p-values for the normothermia, hypothermia and warfarin groups were p<0.05, p<0.01 and p<0.01, respectively). Furthermore, the compression numbers were significantly lower in all of the groups that received Celox ® than in those in which compression alone was applied (p-values for the normothermia, hypothermia and warfarin groups were p<0.01, p<0.01 and p<0.001, respectively). CONCLUSION Celox® provides effective hemorrhage control under conditions of normothermia, hypothermia and use of the oral anticoagulant agent warfarin.

Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department

BACKGROUND The purpose of this study is to detect the mortality predictive power of new Glasgow coma scale, age, and arterial pressure (GAP) scoring system in major trauma patients admitted to the emergency department (ED). METHODS A total of 100 major trauma patients admitted to Uludağ University Faculty of Medicine ED who were 18 years of age or more were included in the study. In this prospective study, revised trauma score (RTS), injury severity score (ISS), trauma-related ISS (TRISS), Mechanism, GAP (MGAP) and GAP scores of the patients were calculated. RESULTS A significant positive correlation was established between ISS, TRISS, MGAP, and GAP in predicting in-hospital mortality (p<0.0001). Short-term (24 hours) and long-term (4-week) mortality prediction rates and area under the curve in receiver operating characteristics analysis were 0.727-0.680 for RTS, 0.863-0.816 for ISS, 0.945-0,911 for TRISS, 0.970-0.938 for MGAP, and 0.910-0.904 for GAP. All calculated trauma scoring systems revealed a significant mortality prediction power (p<0.001). GAP score was found statistically and significantly selective and sensitive in predicting both in-ED and in-hospital mortality (p=0.0001). CONCLUSION In major trauma patients, GAP score is an easily calculable system both in the field and at the time of admission in the EDs by providing emergency physicians with future decision-making schemes by means of mortality prediction of the patients.

Performance of emergency medicine residents in the interpretation of radiographs in patients with trauma.

Background: Radiographs are vital diagnostic tools that complement physical examination in trauma patients. A study was undertaken to assess the performance of residents in emergency medicine in the interpretation of trauma radiographs. Methods: 348 radiographs of 100 trauma patients admitted between 1 March and 1 May 2007 were evaluated prospectively. These consisted of 93 cervical spine (C-spine) radiographs, 98 chest radiographs, 94 radiographs of the pelvis and 63 computed tomographic (CT) scans. All radiological material was evaluated separately by five emergency medicine residents and a radiology resident who had completed the first 3 years of training. The same radiographs were then evaluated by a radiologist whose opinion was considered to be the gold standard. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Results: The mean (SE) age of the patients was 29 (2) years (range 2–79). There were no statistically significant differences in terms of pathology detection between the emergency medicine residents and the radiologist. The agreement between the emergency medicine residents and the radiology resident was excellent for radiographs of the pelvis and the lung (kappa (κ) = 0.928 and 0.863, respectively; p<0.001) and good for C-spine radiographs and CT scans (κ = 0.789 and 0.773, respectively; p<0.001). Conclusions: Accurate interpretation of radiographs by emergency medicine residents who perform the initial radiological and therapeutic interventions on trauma patients is of vital importance. The performance of our residents was found to be satisfactory in this regard.

Clinical probability and risk analysis of patients with suspected pulmonary embolism.

BACKGROUND Pulmonary embolism (PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments as in Turkey. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defined. This study is to find the accurate, fast, non-invasive, cost-effective, easy-to-access diagnostic tests, clinical scoring systems and the patients who should be tested for clinical diagnosis of PE in emergency department. METHODS One hundred and forty patients admitted to the emergency department with the final diagnosis of PE regarding to anamnesis, physical examination and risk factors, were included in this prospective, cross-sectional study. The patients with a diagnosis of pulmonary embolism, acute coronary syndrome or infection and chronic obstructive pulmonary disease (COPD) were excluded from the study. The demographics, risk factors, radiological findings, vital signs, symptoms, physical-laboratory findings, diagnostic tests and clinical scoring systems of patients (Wells and Geneva) were noted. The diagnostic criteria for pulmonary emboli were: filling defect in the pulmonary artery lumen on spiral computed tomographic angiography and perfusion defect on perfusion scintigraphy. RESULTS Totally, 90 (64%) of the patients had PE. Age, hypotension, having deep vein thrombosis were the risk factors, and oxygen saturation, shock index, BNP, troponin and fibrinogen levels as for the biochemical parameters were significantly different between the PE (+) and PE (-) groups (P<0.05). The Wells scoring system was more successful than the other scoring systems. CONCLUSION Biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

Analysis of appropriate tetanus prophylaxis in an Emergency Department.

BACKGROUND In this study, our aim was to identify the validity of the prophylaxis indications for patients who received tetanus prophylaxis, determine the ratio of high-risk wounds to the number of patients with immunity, and to evaluate the tetanus immunity of specific age groups. METHODS Patients who applied to the Emergency Department (ED) between September 2009 and May 2010 and who were considered for tetanus prophylaxis by his/her primary care physician were included in the study. RESULTS A total of 320 patients were evaluated. The average age of the patients was 40.87 ± 15.83 years. A total of 73.1% of the patients were male and 26.8% were female. A total of 40.3% of the patients knew their vaccination history, while 59.7% had no recollection of their vaccination history. 14.7% of the patients had received their last dose within 5 years and 48.1% within 5-10 years; 37.2% of the patients declared that more 10 years had passed since their last vaccination. In 75% of the patients, the tetanus immunoglobulin (Ig)G level was identified as >=0.1 IU/ml, while 25% of the patients had levels <0.1 IU/ml. The number of patients with protective levels was lower among those who were illiterate or who had only a primary school education, and this difference was statistically significant (p<0.001). CONCLUSION The vaccination histories can be misleading. Certain equipment can be used at the bedside to determine a patients tetanus immunization status.

Is Cranial Computerized Tomography Really Necessary for Infants With Minor Head Trauma

Minör kafa travmaları (MKT), çocukluk çağı yaralanmalarının önemli bir kısmını oluşturmaktadır (1, 2). Travma mekanizmaları değişken olmakla birlikte, 2 yaş altında özellikle düşük yükseklikten düşmeler çok sık görülür (3). MKT’lı çocuklarda intrakranial patoloji insidansı %3-5 arasında değişmektedir ve daha genç infantlarda insidans biraz daha yüksektir (4-8). Ancak bu patolojiler nadiren cerrahi müdahale gerektirmektedir (3, 8, 9). Bu hastaların uygun yönetimi halen tartışmalı bir konudur (10). Minör kafa travmalı çocukların çoğu acil servis (AS)’e ya asemptomatik yada minimal semptomlarla gelmektedir (3). Özellikle iki yaş altı çocukların nörolojik muayeneleri zordur, henüz sütürleri kapanmamış olduğundan intrakranial basınç artışını iyi tolere ederler ve bu yüzden bu yaş grubunun MKT’ında radyografik tetkiklerin gerekliliği açısından değerlendirilmeleri oldukça zordur. Seçilecek en iyi görüntüleme yöntemi kranial bilgisayarlı tomografi (BT)’dir (3). Böylece bu yaş grubunda çok fazla kranial BT görüntülemesine gidilmektedir. Değişik çalışmalarda klinisyenlerin MKT’lı çocuklarda tanısal tetkik olarak kranial BT isteme oranı %5-50 arasında değişmektedir (11). Ek Abstract