The Injector

The use of imaging methods instead of clinical findings in the diagnosis of acute appendicitis

Orhan Aslan — 2024-08-20

Dear Editor,

Acute appendicitis (AA) is the most common cause of abdominal pain among the patients admitting to the emergency services. Diagnosis of AA may be difficult; though there are many combinations of laboratory findings and imaging methods, several scoring systems, the diagnosis of AA depends mainly on history taking and physical examination. AA occurs at any age, mostly in 2 and 3 decades. While the lifetime risk of acute appendicitis is 6.7% in women, it is slightly higher in men and is 8.6% (1). Its annual incidence is arround 100-150 per 100.000 people (2). Complicated appendicitis is classified as perforated appendicitis and plastron appendicitis.

Due to technological developments, it is aimed to make rapid diagnosis by increasing the use of imaging methods such as ultrasonography and computerized tomography (CT) in the emergency departments. So that, physicians waste time on patient history and physical examination. The different findings in the different imaging methods maybe confusing and the diagnosis maybe more challenging.

Many patients might be sent home with antibiotic treatments and return later with complications due to delay in diagnosis. Despite the increasing number of tests and imaging methods used, the rate of delayed diagnosis of AA was reported 26.2% in a recently published study. It was emphasized that this rate was higher than previous studies (3).

Moreover many clinical scoring systems have been developed to determine the probability of AA and rule out other diseases with abdominal pain. Alvarado score, Appendicitis Inflamatory Response (AIR) score and Adult Appendicitis score is among most popular systems (4). These scores mainly include patients complaints as nausea, vomiting, anorexia, increase in white blood cell count, palpation of right lower quadrant pain, rebound tenderness, increase in body temperature and leukocytosis shift. A diagnostic method combining clinical scoring systems with imaging technics has not been described. Improper combination of imaging methods and clinical tests may cause misdiagnosis of early appendicitis. For decades diagnosis of AA has been made by history taking and physical examinations. Later laboratory tests have been added and imaging technics have emerged. CT has become the technique of choice between imaging methods. New devices are faster and can view more patients. Therefore, physicians have become more dependent on more imaging methods. As a result of imaging-dependent patient management, early stage of acute appendicitis can be misdiagnosed. More plastron or perforated appendicitis are seen in the operation room though this should be the reverse. Also it should be remembered that repeated use of CT exposes significant amount of radiation to the patient.

In conclusion, physicians can research for new methods in the diagnosis of acute appendicitis and use different scoring systems according to the findings, but basic methods such as physical examination and patient history should not be leave.

Why did you order this test?

Musa Yılmaz — 2024-08-21

Dear Editor,

I would like to share my concerns about the increase in the number of laboratory tests in healthcare services in recent years and the harms of unnecessary test orderings. This situation causes significant problems both in the health system and in patient care.
Over the past years, a noticeable increase in the number of laboratory tests has been observed. According to a study conducted in Turkey, there was a continuous increase in the use of laboratory tests between 2015 and 2019, and this increase has serious impacts on hospital costs (1). Additionally, a study in 2023 shows that using the ARIMA (Auto Regressive Integrated Moving Average) model to forecast laboratory expenditures, it is expected to reach 380 billion Turkish Liras in 2023, 538 billion Turkish Liras in 2024, and 694 billion Turkish Liras in 2025 (2). Various reasons contribute to this increase. One is that advancements in laboratory technologies enable faster and more comprehensive tests, which can also lead to an increase in unnecessary test orderings. Another reason is that physicians tend to order more tests to avoid possible legal issues, which leads to an increase in unnecessary test orderings (3). Unnecessary laboratory test orderings have various adverse effects on the health system and patients.

To discuss them under main headings:

Cost increase; unnecessary tests cause significant costs in the health system. A study in Turkey shows that unnecessary laboratory tests cost public hospitals billions of Turkish Liras annually (1). These costs strain the health budget and hinder the effective use of resources. This situation is similar in many countries.

Patient safety and health risk; unnecessary tests can create additional stress and health risks for patients. False positive results can expose patients to unnecessary treatments and further tests, posing a serious threat to patient safety (4).

Resource waste; the effective use of health resources is becoming increasingly important. Unnecessary test orderings waste the time of healthcare staff and laboratory resources (4).

Patient satisfaction; unnecessary tests can undermine patients’ trust in the health system. Patient satisfaction should be ensured by conducting appropriate and necessary tests.

Ethical issues; unnecessary test orderings also raise ethical issues. Ethical medical practices require avoiding unnecessary interventions.

In conclusion, the increase in the number of laboratory tests and the harms of unnecessary test orderings lead to significant problems in the health system and patient care. To prevent these problems: physicians and health professionals should be more careful and aware when ordering tests, health authorities should create guidelines and protocols to prevent unnecessary test orderings, patients should be informed and their awareness should be raised to avoid unnecessary tests. I wrote this article to highlight this important issue and to improve the quality of healthcare services.

Key points in the success of diabetic foot ulcer treatment

İsmail Sezikli — 2024-08-21

Dear Editor,

Diabetic foot ulcers (DFUs) represent a significant challenge in diabetic patient care due to their chronic nature and potential for severe complications, including infection and amputation. Recent advances in understanding the pathophysiology and management of DFUs have highlighted several critical areas that can enhance treatment success.

Timely identification of patients at risk for DFUs is paramount. Tools such as the Diabetic Foot Risk Classification System enable clinicians to stratify patients based on ulcer risk, facilitating early interventions (1). Regular foot examinations and patient education on self-monitoring can significantly reduce ulcer incidence (2).

A comprehensive, multidisciplinary approach is essential for effective DFU management. Involving endocrinologists, podiatrists, vascular surgeons, and wound care specialists ensures that all aspects of patient care are addressed, from glycemic control to wound management (3). Multidisciplinary clinics have shown to improve outcomes and reduce amputation rates (4).

The introduction of advanced wound care technologies has revolutionized DFU treatment. Negative pressure wound therapy (NPWT), bioengineered skin substitutes, and growth factor therapies have demonstrated efficacy in promoting wound healing (5). NPWT, in particular, has been associated with faster healing times and reduced infection rates (5).

Infection is a common and serious complication of DFUs. Effective management requires accurate diagnosis and targeted antibiotic therapy. The use of modern molecular diagnostic tools has improved the identification of pathogens, allowing for more precise treatment (6). Additionally, antibiotic stewardship programs are crucial to preventing resistance and ensuring the effectiveness of available treatments (7).

In conclusion, the management of diabetic foot ulcers requires a holistic and patient-centered approach, integrating early detection, multidisciplinary care, advanced therapies, and patient education. Continued research and innovation in treatment strategies are essential to further improve outcomes for patients with DFUs. By focusing on these key areas, healthcare providers can enhance the success of DFU treatment and improve the quality of life for diabetic patients.

Controversies in patient selection; is the colonic perforation after colonoscopy well-known?

Aşkın Kadir Perçem — 2024-08-21

Dear Editor,

Ageing of populations and concern about malignant lower gastrointestinal dieases increased referrals for colonoscopy. Our concern here is to express the risk factors for colonic perforation (CP) which is known to be the most serious complication of colonoscopy and the doubt for patent selection. Colonoscopy is the best method for detecting the colon cancer and precursor lesions of colon cancer such as polyps. As the number of diagnostic and therapeutic colonoscopies increase, CP is more often seen. CP rates vary from 0.08% to 0.14% for diagnostic colonoscopies. For therapeutic colonoscopies perforation may be seen up to 5% (1). Mechanical force is the most important culprit of CP after diagnostic colonoscopy while perforation due to polypectomy is the most common complication of therapeutic colonoscopy. Rectosigmoid junction and sigmoid colon are the most susceptible sites for CP because of mobility and sharp angulation of sigmoid colon. Forcefull insertion of colonoscope's tip at rectosigmoid junction or shearing stress applied by the shaft due to overextention of colon while forming a sigmoid loop are the reasons of CP at the anti-mesenteric region. Barotrauma is mainly the cause of perforation at caecum due to insuflation with excessive air. Intraabdominal adhesions following previous operations or pelvic inflamatuary disease, inflamation of sigmoid colon due to diverticulitis by thinning and making the bowel wall fragile compromises CPs. Old age and female gender are among the risk factors of CP. In patients older than 75 years of age CP rates are 5-6 times more than the younger population. Sharp angulation of the rectosigmoid junction make female gender more susceptible to the colonic perforation than men. Also the length of the colon is more in females enabling loop formation and CP (2). Inflammatory bowel diseases, colonic obstruction due to tumors, corticosteroid use are among the other risk factors of CP. Polypectomy of polyps larger than 2 cm increase the risk of perforation after therapeutic colonoscopy. Also stenting of tumoral lesions or strictures caused by inflammatory diseases increase the risk of perforation (3). Most of these risk factors are patient-related. However, the most important endoscopist-related factor is endoscopy experience. Indeed, in a recently published retrospective study of 74,486 colonoscopy cases, it was emphasized that endoscopist experience is an important risk factor for CP. It was reported that 16 (84%) of the 19 CPs in the study occurred during the endoscopists' first 1,000 endoscopic experiences (4). This complication of colonoscopy may be devastating and lethal. Therefore patient selection becomes very important. Stigmata for colon cancer may be diverse such as anemia, hemorrhage, abdominal pain, weight loss and positive gaita test for blood. Early detection and removal of polyps can protect the patient from colon cancer and possible chemotherapy harms, but because it is an invasive procedure, the risk of perforation is higher than with diagnostic colonoscopy. Also diagnosis and follow up of inflamatory bowel diseases is an other dillemma in patient selection. Low sensitivity of the tests such as gaita and diagnostic variables prevents right patient selection. Many patient is unaware of the procedure and its complications. Awareness of patients and ideal patient selection may make the procedure safer.

In conclusion, since CP is a serious complication, physicians should pay attention to the ideal patient selection for colonoscopy and avoid unnecessary colonoscopy. Considering the risk factors mentioned above, it would be beneficial to have the procedure performed by an experienced endoscopist, especially in high-risk patients. In addition, the low sensitivity of current blood and stool tests leads to more patients being referred for colonoscopy. Later new diagnostic tests may change the era and prevent colonoscopies and its complications for healthy patients.

Diagnostic effectiveness of wire-guided localization for non-palpable breast lesions and its importance in breast cancer management

Orhan Aslan — 2024-08-15

Objective: Breast cancer represents the most prevalent malignant disease among women globally, accounting for approximately 30% of all female cancers. Wire-guided localization is now a commonly utilized method for diagnosing breast lesions that are not palpable on clinical examination but can be identified through the use of mammography (MG) and/or ultrasound (US). The objective of the study was to determine the cancer prediction rate of the method in patients with non-palpable breast lesions who underwent excisional biopsy with wire guided localization and to evaluate the diagnostic significance of the method by comparing age, size, family history, radiomorphologic type, Breast Imaging and Data System (BI-RADS) category, location, and histopathologic features. Furthermore, the objective was to elucidate the advantages of the method in breast cancer treatment by determining the re-excision rates and types according to the surgical margin status of malignant lesions.

Methods: The study was planned retrospectively. A total of 228 histopathologically examined lesions that underwent US or MG-guided wire-guided excisional biopsy for non-palpable breast lesions between June 2006 and December 2011 were included in the study.

Results: Of all lesions, 58 (25.4%) were diagnosed as malignant, while 170 (74.6%) were diagnosed as benign pathologies. The cancer prediction rate of the method was determined to be 25.4%. The malignancy rate demonstrated a statistically significant correlation with age, with an increasing trend observed with advancing age (p=0.006). No statistically significant differences were observed between malignant and benign lesions with respect to size, localization, or family history. With regard to lesion type, the malignancy rate was higher in lesions comprising microcalcification clusters (p=0.005). Malignancy rates were significantly higher in the BI-RADS 4b (OR:6.06) and BI-RADS 4c (OR:6.77) groups compared to the other BI-RADS categories. In cases where the surgical margins were positive for malignancy (28/58), the rate of mastectomy was significantly higher than in cases where the margins were negative (p=0.006). The majority of malignant lesions (79.3%) were classified as stage 0 or 1 cancers.

Conclusion: Wire-guided localization is still an effective method for early diagnosis of breast cancer and identification of suspicious non-palpable lesions. Developing new techniques in pathology, radiology, and surgery to better localize suspicious non-palpable lesions and reduce surgical margin positivity rates will facilitate the fight against breast cancer.

The effect of gelatine, pure olive oil and hyaluronic acid on postoperative intraabdominal adhesions

Yavuz Pirhan — 2024-08-28

Objective: In patients who have undergone abdominal surgery, serious adhesions are often encountered in cases of repeated abdominal surgery and problems occur in separating the intraabdominal organs. The aim of this experimental study was to investigate the effects of Gelofusine®, Gelofusine plus pure olive oil, and Gelofusine plus hyaluronic acid administered to the abdomen during operations on intraabdominal adhesions that may occur after surgery.

Methods: Forty adult female Wistar albino rats weighing 200-300 g were used in the study. Rats were randomly divided into 4 separate groups with 10 animals in each group. The abdomen was entered after a 2-cm skin and subcutaneous incision along the midline of the abdomen, and then abrasion was applied to the serosa above the cecum and the right lateral peritoneal surface of the abdomen with a 1-cm child’s toothbrush. In the experimental groups, Gelofusine, Gelofusine plus pure olive oil, or Gelofusine plus hyaluronic acid was applied and the abdomen was anatomically closed with 4/0 Prolene threads in two layers. On the 21st day, all animals were euthanized and evaluated both macroscopically and histopathologically. In the control group, after the abdomen was opened and abrasion was applied, no liquid or other substance was administered and the abdomen was closed.

Results: No adhesions were observed macroscopically in one rat in Group 1, in nine rats in Group 2, in seven rats in Group 3, and in four rats in Group 4. Varying degrees of inflammation were found in the rats of all groups. However, fibrosis was not observed in Group 2. When the groups were compared, there was a statistically significant difference between the control group and the group in which only Gelofusine (Group 2) was applied (p<0.05).

Conclusion: Although significant results were expected in the groups in which pure olive oil and hyaluronic acid were used, only Gelofusine, which contains gelatin as an active ingredient and is used in routine human treatment, was found to be statistically and macroscopically significant in preventing intraabdominal adhesions compared to the other groups.

Evaluation of iron deficiency anemia in preterm and low birth weight infants

Eren Güzeloğlu — 2024-08-17

Objective: Anemia affects 571 million women of reproductive age and 269 million children under the age of five, constituting a significant global public health concern. In line with the WHO/UNICEF 2030 Sustainable Development Goals, it is aimed to reduce the prevalence of anemia worldwide, especially in women of reproductive age and children, by 15% in 2025. This study evaluated preterm and low-birth-weight infants for iron deficiency anemia.

Methods: This study included preterm and low-birth-weight infants followed in our clinic between 2020 and 2022 (24 months). It was a retrospective cohort study. Complete blood count results obtained at the time of birth and/or during hospitalization in the neonatal intensive care unit were evaluated. Complete blood count, ferritin, and iron values routinely measured in the outpatient clinic at 12-month control appointments were also evaluated.

Results: We followed 203 cases between 1 January 2020 and 1 January 2022. While 50.2% (n=102) of the patients were male, 49.8% (n=101) were female and the cases included 12 twins (5.9%). Data analysis revealed that 6.4% of the infants were extremely early preterm (n=13), 19.7% were very early preterm (n=40), 18.7% were moderately preterm (n=38), and 55.1% were late preterm (n=112). Furthermore, 69.4% had low birth weight (n=141), 63% had very low birth weight (n=128), and 6.4% had extremely low birth weight (n=13). When hemoglobin values were compared between infants given and not given iron prophylaxis, statistical significance was found in terms of anemia (p=0.04).

Conclusion: To prevent anemia in preterm and low-birth-weight children, iron prophylaxis should be started in the early period. Families should be informed about immunization, nutrition, and follow-up. It is important to intervene when anemia develops with close cooperation among neonatologists, pediatricians, and family physicians.

Evaluation of the efficacy of aged garlic extract in reducing neuronal damage in rats with spinal cord ischemia-reperfusion injury

Fahri Eryılmaz — 2024-08-18

Objective: Aged garlic extract (AGE) is known to improve human well-being via its anti-inflammatory/antioxidant and neuroprotective properties. The purpose of this study was to evaluate the possible pathological, neurological, biochemical, and ultrastructural benefits of AGE in a rat model of spinal cord ischemia-reperfusion (I-R).

Methods: Thirty Sprague-Dawley rats were randomly divided into three groups: I-R, sham (no I-R), and AGE (I-R+AGE), with 10 rats in each group. Neurologically, the rats were assessed with the help of the Basso, Beattie, and Bresnahan (BBB) scoring system. Spinal cord tissue samples were collected for ultrastructural and neurological evaluations. Oxidative markers (malondialdehyde and nitric oxide), antioxidants (glutathione peroxidase, catalase, and superoxide dismutase), inflammatory cytokines (interleukin-1 and TNF-alpha), and caspase-3 were measured.

Results: The AGE group had higher BBB scores in comparison to the I-R group (p<0.05). The AGE group pathologically demonstrated a decreased level of edema of the spinal cord and ischemia (p<0.05). The ultrastructural findings revealed that the tissue structure was preserved in the AGE group. The levels of oxidative markers in the I-R group were higher than those of the other two groups, while the levels of antioxidant enzymes were higher in the AGE group than in the I-R group and the difference between the groups was significant (p<0.05). The sham group and AGE group differed significantly in terms of levels of antioxidant enzymes (p<0.05). Moreover, the administration of AGE reduced caspase-3 activity and inflammatory cytokines in comparison to the I-R group (p<0.05).

Conclusion: This study shows the significant neuroprotective effects of AGE on the pathological, neurological, biochemical, and ultrastructural variables of a rat model of I-R injury of the spinal cord.

Investigation of serological response to COVID-19 among healthcare workers using four different kits

Saadet İbiş — 2024-08-19

Objective: This study aimed to investigate the serological response to SARS-CoV-2 among healthcare workers at a hospital in Turkey using kits from four different companies.

Methods: The study included 120 healthcare workers who received the Sinovac vaccine at a Turkish hospital. Serum samples were collected from these participants who had received the Sinovac vaccine ata median of 1 month after administration of the second dose. Samples were tested using the Abbott SARS-CoV-2 IgG II Quant, Beckman Coulter Access SARS-CoV-2 IgG, Maglumi 2019-nCoV IgG, and Siemens Advia Centaur SARS-CoV-2 IgG test kits. In the presented comparative study, the results of the different immunoassay analyzers were compared. Relationships among the results were evaluated by comparing the levels of antibodies against spike proteins.

Results: The results of the antibody analyses differed according to the kits that were used. The Abbott SARS-CoV-2 IgG II Quant test was positive for 44.17% and negative for 55.83% of the participants, the Access SARS-CoV-2 IgG test was positive for 80.83% and negative for 19.17%, the Maglumi 2019-nCoV IgG test was negative for 55% and positive for 45%, and the Advia Centaur SARS-CoV-2 IgG test was positive for 88.83% and negative for 11.67%. The number of participants who tested positive when the Abbott kit was used differed significantly compared to other analysis kits (p<0.0001). The difference between the Beckman Coulter and Maglumi kits was not significant (p>0.37), but the difference between the Maglumi and Siemens kits was significant, with the positivity rate of the Siemens kit being significantly higher (p<0.0001).

Conclusion: This study has confirmed that serological tests produced by different manufacturers can be used to identify individuals exposed to the COVID-19 virus and to assess the exposure rate of the community.