Yusuf Alper Kilic

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.

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery

BACKGROUND The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.

A Gastrointestinal Stromal Tumor in Meckel Diverticulum in an 86-Year-Old Patient

Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract. Its prevalence is approximately 2% of the general population. Complications because of Meckel diverticula are rare and almost nil beyond the age of 40 years. This report details the case of an 86-year-old patient with Meckel diverticulum that perforated because of a tumoral lesion at its apex, also known as volvulus of Meckel diverticulum.

A Novel Fuzzy Logic Inference System for Decision Support in Weaning from Mechanical Ventilation

Weaning from mechanical ventilation represents one of the most challenging issues in management of critically ill patients. Currently used weaning predictors ignore many important dimensions of weaning outcome and have not been uniformly successful. A fuzzy logic inference system that uses nine variables, and five rule blocks within two layers, has been designed and implemented over mathematical simulations and random clinical scenarios, to compare its behavior and performance in predicting expert opinion with those for rapid shallow breathing index (RSBI), pressure time index and Jabour’ weaning index. RSBI has failed to predict expert opinion in 52% of scenarios. Fuzzy logic inference system has shown the best discriminative power (ROC: 0.9288), and RSBI the worst (ROC: 0.6556) in predicting expert opinion. Fuzzy logic provides an approach which can handle multi-attribute decision making, and is a very powerful tool to overcome the weaknesses of currently used weaning predictors.

Visualizing multiple organ failure: a method for analyzing temporal and dynamic relations between failing systems and interventions.

Multiple organ failure is the common clinical course of critical patients who have prolonged stay in the

Injuries to the Spleen

Background:Intra-abdominal organs, most commonly the spleen and liver, are injured in 40–50% of polytraumatized patients. Because of its important immunological functions, preservation of the injured spleen is of paramount importance.Methods:There are both conservative and surgical approaches to preservation of the spleen in trauma cases. Of the techniques available for this purpose, tissue adhesives, coagulation, partial resection, and mesh splenorrhapy are the most suitable.Results:Nonoperative management is a worthwhile option in hemodynamically stable patients. The decisive factor for successful conservative management is the degree of injury. We find that the manner in which heparin is administered plays an important role. Tissue adhesives are commonly used with good success with superficial lacerations. Coagulation techniques are also suitable for organ conservation with grade I and II injuries. Splenorraphy with resorbablemesh is the method of choice with the deep lacerations as it permits rapid and permanenthemostasis. If an injury only involves one pole or one half of the spleen, resection of that part of the organ is an option. Partial resection with a stapler is advisable for speed and effectiveness. Total fragmentation or separation of the hilus is treated with an immediate splenectomy, saving the tail of the pancreas.Conclusion:In trauma cases, every attempt should be made to save the spleen. If splenectomy cannot be avoided, the splenectomized patient should be immunized against pneumococcus and be informed of his/ her resultant immune deficiency.

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.

Archery-Related Sports Injuries

The reported archery-related sports injuries mostly comprise shoulder and soft tissue injuries caused by repetitive draw on the bow. Archery-related accidental penetrating injuries are quite rare, but considering the increasing popularity of traditional archery, there is a potential threat of increase in their incidence. The extent of penetrating arrow trauma depends on the draw weight of the bow, design of the arrow head, the range at which the arrow is released, and the tissues encountered on target. Penetrating arrow wounds carry a lethal potential. Due to the elasticity of tissues, pressures exerted by the shaft of the arrow can partly tamponade bleeding from surrounding tissues and vessels. Before an attempt of removal, trajectory of the arrow and potential injuries should be assessed appropriately. The musculoskeletal injury patterns are closely related to stance of the archer, and the technique used during the draw, aim, and release phases. These injuries benefit from physical rehabilitation and appropriate modifications in stance of the archer.

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.

Sepsis and multiple organ failure represent a chaotic adaptation to severe stress which must be controlled at nanoscale

We claim that sepsis and multiple organ failure represent an adaptive process that aims a survival advantage. Dynamic nature of sepsis comprise all of the key properties of a chaotic system. Chaotic and complex systems actually aim order and integrity, and their behaviours cannot be explained by linear statistical methods. Thats why pathophysiology of sepsis and multiple organ failure must be re-modeled within the context of chaos and complexity theories. We also claim that one of the underlying reasons of difficulty in bench to bedside transition of experimental data is the difficulty in applying therapies at the proposed level of action. This decreases the efficacy and safety of treatment. Application of tools provided by nanotechnology can serve to design better therapies that can apply treatment and monitor its results at the level of proposed effect, and instantly modify the amplitude and direction of therapy accordingly at molecular or cellular level.