High therapeutic potential for systemic delivery of a liposome-conjugated herpes simplex virus

PURPOSE

Oncolytic viral therapy is a newly developed modality to treat tumors. Many clinical trials worldwide have examined the efficacy of locally injected oncolytic viruses. However, systemic intravascular injections are limited by the humoral immune response, which dramatically decreases the level of infection. To overcome this limitation, we encapsulated the oncolytic virus in liposomes.

METHODS

The infectious properties of the herpes simplex virus type 1 (HSV-1) mutant, hrR3, with or without liposomes in the presence of neutralizing antibodies were evaluated using replication and cytotoxicity assays in vitro. To evaluate the efficacy of intravascular virus therapy with liposomes in the presence of neutralizing antibodies, immunized mice bearing multiple liver metastases were intraportally or peritoneally administered hrR3 or hrR3 complexed with liposomes.

RESULTS

Anti-HSV antibodies attenuated the infectiousness and cytotoxicity of hrR3, whereas hrR3/liposome complexes were not attenuated by these anti-HSV antibodies. Although the survival rate of non-immunized mice treated with hrR3 alone was similar to that of mice treated with the hrR3/liposome complexes, the survival rates of immunized mice treated with hrR3 alone were significantly reduced compared to mice treated with the hrR3/liposome complexes.

CONCLUSIONS

This systemic intravascular delivery of hrR3/liposome complexes in the presence of pre-existing neutralizing antibodies is effective to treat multiple liver metastases.

Gamma glutamyl transpeptidase as a prognostic biomarker in hepatocellular cancer patients especially with >5 cm tumors, treated by liver transplantation

Background

Serum AFP levels are typically elevated in less than 50% of hepatocellular cancer (HCC) patients. Gamma-glutamyl transpeptidase (GGT) levels have been suggested to be a potentially useful HCC biomarker.

Aims

To assess in a cohort of prospectively evaluated HCC patients who underwent liver transplant and whose survival was known; the occurrence, prognosis, and clinical characteristics of patients with elevated serum GGT levels.

Results

Serum GGT levels were found to be elevated in a higher proportion in patients with either small or large HCC than alpha-fetoprotein (AFP) levels, and were significantly related to prognosis in patients with large size HCCs. There was no clear correlation between GGT and AFP levels, likely reflecting different HCC characteristics or HCC cell lineages associated with these two markers. Furthermore, elevated GGT was found in 24% of low-AFP patients with small tumors and 46% with large tumors. Elevated GGT levels were also significantly associated with microvascular invasion and tumor diameter.

Conclusions

Elevated serum GGT levels were associated with HCC size and worse survival, and were unrelated to AFP levels. GGT may be a useful prognostic tumor marker, especially for low-AFP HCC patients.

Comment on pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality

Since the first successful liver transplantation was performed five decades ago, pediatric liver transplantation has become the gold standard treatment choice for pediatric liver disease, including metabolic diseases, liver tumors, and some acute liver failure. With improvements in immunosuppression, surgical techniques, and postoperative medical care, long-term outcomes of patients after liver transplantation have markedly improved, especially in pediatric patients.

Microvascular Venous Invasion in Hepatocellular Carcinoma: Why Do Recurrences Occur?

PURPOSE

Hepatocellular carcinoma is the most common primary cancer of the liver. It is almost always associated with cirrhosis and it is usually diagnosed in later stages of the disease. Furthermore, recurrence rate following liver transplantation ranges between 15 and 30%. The most important factor determining the recurrence is vascular invasion.

METHODS

In this review, the issue of microvascular invasion causing hepatocellular carcinoma recurrence is reviewed. Macroscopic vascular invasion is almost easy to diagnose on radiologic evaluation. However, microscopic vascular invasion is almost always diagnosed with pathologic evaluation. On the other hand, microscopic vascular invasion is associated with early recurrences and reduced disease-free survival. The type of vessel that is invaded determines the nature of the spread of the tumor cells. Invasion of the hepatic venous tributaries leads to systemic metastasis whereas portal venous invasions lead to intrahepatic spread of the tumor. Microscopic vascular invasion should be diagnosed before liver transplantation or liver resection in order to deliver the appropriate therapy to the patients.

RESULTS

Yet, there is no ideal marker to suggest microscopic vascular invasion before any intervention. Markers such as alpha-fetoprotein, des carboxy prothrombin, or gamma-glutamyl transferase have been found to be correlated with microscopic vascular invasion. These parameters are not very efficient to be used in routine clinical practice.

CONCLUSION

Therefore, further research is needed to define ideal marker associated with microscopic vascular invasion.

Tryptophan degradation and serum neopterin concentrations in intensive care unit patients

Alterations in neopterin concentrations and tryptophan degradation accompany the activation of cellular immune systems. Accordingly, in a variety of diseases, mainly in infections, elevated neopterin levels and tryptophan degradation have been observed. This study aimed to assess serum neopterin levels and tryptophan degradation in intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS, n = 9), sepsis (n = 8), septic shock (n = 10), and multiple organ dysfunction syndrome (MODS, n = 7) at the first day of ICU hospitalization. The kynurenine-to-tryptophan (kyn/trp) ratio was used in order to evaluate the degree of tryptophan degradation. The results of each patient group were compared with the control group (n = 30). The differences among the ICU groups and the correlations between APACHE II scores and neopterin concentrations or tryptophan degradation were investigated. All patient groups presented statistically higher kyn/trp and neopterin levels than the controls. The sepsis, septic shock, and MODS group had markedly higher neopterin levels than the SIRS group (all P < 0.05). Additionally, it was found that the survivor group had significantly lower neopterin levels compared with non-survivors (P < 0.05) and lower kyn/trp, but the latter difference was not significant. Neopterin levels and kyn/trp were both correlated with APACHE II score (both P < 0.05). The results indicate that serum neopterin levels and tryptophan degradation correlate well with the severity of the disease in ICU patients, and this was true even at the first day of hospitalization in the unit.

STEAP4 and HIF-1α gene expressions in visceral and subcutaneous adipose tissue of the morbidly obese patients

AIM AND BACKGROUND

Obesity is a multifactorial disease in which environmental and genetic factors play an integrated role. Determining such target genes will help to elucidate the mechanisms underlying complex diseases such as obesity and diabetes which are usually seen together. Present study investigates the expression levels of STEAP4 and HIF-1α in visceral and subcutaneous adipose tissue.

PATIENTS AND METHODS

30(6M) morbidly obese patients undergoing bariatric surgery were included in the study. The patients were grouped according to the BMI as Group I (BMI <50kg/m(2)) and Group II (BMI ≥50kg/m(2)). Samples from visceral (omentum) and subcutaneous adipose tissues were obtained from each patient and real-time PCR (qPCR) was carried out for STEAP4 and HIF-1α gene expressions. Correlations between expression levels and clinical parameters were analyzed.

RESULTS

Mean age of the patients recruited to the study was 37.4 (18-64) years. Mean BMI was 46 (36-60) kg/m(2). STEAP4 expression in visceral adipose tissue was significantly higher than subcutaneous tissue. Visceral STEAP4 expression was also found to be reduced with increased BMI. It was also lower in patients with HbA1C over 6. Furthermore, expression of subcutaneous and visceral HIF-1α was significantly higher in Group II. There was a significant correlation between BMI, glycosylated hemoglobin, STEAP4 and HIF-1α gene expression.

CONCLUSIONS

Obesity and related disease are linked with the fact that there is a low grade inflammation in the adipose tissue of the obese individuals. Counter-regulatory processes such as STEAP4 protein family are overwhelmed by the proinflammatory stimuli. HIF-1α expression is increased due to tissue hypoxia and pro-inflammatory stimuli in the obese individuals, which results in increased visceral STEAP4 expressions.

Effects of the probiotic agent Saccharomyces Boulardii on the DNA damage in acute necrotizing pancreatitis induced rats

Pancreatitis is a mild and self-limiting disease. Although severe forms such as acute necrotizing pancreatitis (ANP) are rare it is associated with significant mortality rate reported to be 30-70%. Probiotics are viable microbial dietary supplements when introduced in sufficient quantities can have beneficial effects. The physiological effects of probiotics include suppression of bacterial infections, production of some digestive enzymes and vitamins and reconstruction of normal intestinal microflora. In the present study, the aim was to investigate the role of probiotics on the DNA damage in the peripheral lymphocytes, in the exfoliated epithelial cells and lymphocytes of the peritoneal fluids and in the pancreatic acinar cells of ANP induced rats. DNA damage was determined by COMET assay. ANP was induced by intravenous infusion of cerulein and superimposed infusion glycodeoxycholic acid into biliopancreatic duct. Saccharomyces Boulardii was used as the probiotic agent. DNA damage in pancreatic acinar cells and exfoliated epithelial cells and the lymphocytes of the peritoneal fluids was significantly higher in pancreatitis group compared to the controls and probiotic treated groups (P<0.001). No significant difference was observed in the DNA damage between the groups in the peripheral lymphocytes. In conclusion; our results support that probiotic agent Saccharomyces Boulardii can diminish bacterial infections and offer health benefits in the therapy of pancreatitis.

Keyhole deformity: a case series

OBJECTIVE

Keyhole deformity is frequently encountered after posterior internal sphincterotomy but may be observed after lateral internal sphincterotomy or in patients without any history of previous anal surgery. The aim of the present study is to emphasize the surgical significance of this entity and discuss the possible strategies in the treatment of the deformity.

MATERIAL AND METHODS

Patients in whom keyhole deformity developed after surgical or conservative treatment applied for chronic anal fissure in our clinic and patients referred from other centers were recruited.

RESULTS

Nine-hundred twenty-six patients were treated for chronic anal fissure. A hundred of these patients directly underwent lateral internal sphincterotomy. The remaining 826 patients initially received conservative management, and 676 of them eventually underwent lateral internal sphincterotomy. In total, 15 patients were diagnosed to have significant keyhole deformity. Initially, all patients received conservative treatment for keyhole deformity, which was successful in two patients. Of the 13 patients in whom conservative management failed, nine underwent advancement flap reconstruction and the remaining four diamond flap reconstruction.

CONCLUSION

Keyhole deformity is occasionally seen as a late complication of chronic anal fissure and may be well tolerated by the patients without any well-defined symptoms. The treatment strategy is directed toward the degree of functional alteration.

Neopterin, Catalase and Superoxide Dismutase in Females with Benign and Malignant Breast Tumors

The aim of the present study was to evaluate the relationship between the levels of neopterin among patients with benign and malignant breast disease and the relation with the stage of the malignant process. In this study, neopterin concentrations and enzyme activities of superoxide dismutase (SOD) and catalase (CAT) were determined in malign (n=30) and benign breast tumor patients (n=30) by high performance liquid chromatographic and spectrophotometric methods, respectively. Results were compared with a healthy control group (n=20). The correlations between neopterin, CAT and SOD were also evaluated in controls and patients. Urinary neopterin level of the control group was (mean value ± S.D.) 128.6 ± 64.6 μmol/mol creatinine. Neopterin concentrations in patients with breast malignancy were 153.6 ± 71.2 μmol/mol creatinine and 107.8 ± 32.1 μmol/mol creatinine in benign disorders patients. The mean neopterin level in the benign group was found to be statistically different from the malign tumor group (p = 0.039). SOD and CAT activities in controls were found as 3.57 ± 0.84 U/mg protein and 2.19 ± 0.20 U/mg protein, respectively. In patients with malignancy, the SOD activity was 3.84 ± 0.73 U/mg protein while CAT activity was 1.03 ± 0.13 U/mg protein. Patients with benign breast disorders, SOD activity was 4.09 ± 1.00 U/mg protein and CAT activity was 1.02 ± 0.18 U/mg protein. Whereas SOD activity did not differ between the groups of patients and controls, the mean catalase level in the control group was higher than in the benign and malign tumor groups (both p <0.001). Urinary neopterin concentration seems to be an important and useful biomarker in diagnosis of breast tumors in clinical practice.

Coronavirus Precautions: Experience of High Volume Liver Transplant Institute

BACKGROUND

To present the struggle of a high volume liver transplant center against coronavirus infectious disease-2019 pandemic.

METHODS

Between March 2020 and December 2020, the demographic and clinical data of staff and liver transplant candidates diagnosed with coronavirus infectious disease-2019 in our Liver Transplant Institute were prospectively analyzed.

RESULTS

First, 32 healthcare staff were diagnosed with coronavirus infectious disease-2019, and 6 of them were surgeons. Six staff were asymptomatic, while 24 staff had mild or moderate and 2 staff had severe coronavirus infectious disease-2019. All the staff recovered from the disease without any permanent sequela and returned to duty after 2 consecutive negative polymerase chain reaction results within 24-hour intervals. Second, during the preoperative investigation, 6 living liver donor candidates and 13 recipients were tested positive for coronavirus infectious disease-2019 (son = 6, unrelated = 3, cousin = 3, daughter = 2, cadaveric = 1). Eleven patients received favipiravir and 8 did not receive any treatment because they were asymptomatic. Only one recipient who had severe coronavirus infectious disease-2019 died due to multiple organ failure syndrome. One recipient died in the early postoperative period. The median duration from the initial diagnosis of the patients till the transplant procedure was 21 days (min-max: 14-105 days). During the time of operation, the polymerase chain reaction tests of the donors and the recipients were negative, and the thorax tomography images showed no signs of viral pneumonia.

CONCLUSION

Meticulous precautions, multidisciplinary approach, team effort, and organization of facilities can increase the quality of care of these patients in the coronavirus infectious disease-2019 era. Healthcare workers have shown tremendous effort and are the true heroes of this era.

Combination of the tumor angiogenesis inhibitor bevacizumab and intratumoral oncolytic herpes virus injections as a treatment strategy for human gastric cancers

BACKGROUND/AIMS

Advanced gastric cancer is difficult to treat due to the frequency of liver metastases and peritoneal dissemination. A combination of two new strategies, including the anti-angiogenesis inhibitor bevacizumab and an oncolytic herpes virus is a promising treatment for advanced cancer.

METHODOLOGY

The effects of bevacizumab on oncolytic herpes virus replication and viral cytotoxicity were examined at varying bevacizumab concentrations and viral titers. In addition, the ability of these two new promising anticancer agents to inhibit tumor growth was studied. Histological examinations of CD31 and LacZ were used to assess angiogenesis and virus distribution within the tumor, respectively.

RESULTS

Bevacizumab did not affect viral replication or viral cytotoxicity in vitro. The combination of bevacizumab and the oncolytic herpes virus hrR3 significantly reduced tumor growth in vivo in an experimental gastric cancer model. Bevacizumab inhibited angiogenesis caused by local injection of hrR3 and induced virus spread. Bevacizumab increased the distribution of the intratumorally injected oncolytic herpes virus within the tumor.

CONCLUSIONS

Combination therapy consisting of bevacizumab and an oncolytic herpes virus is a promising new treatment strategy for gastric cancer.

Immune system modulation in patients with malignant and benign breast disorders: tryptophan degradation and serum neopterin

Tryptophan degradation metabolites are known to suppress T-cell function, which is a mechanism of resistance of tumor cells against immune surveillance. The aim of this study was to evaluate tryptophan degradation along with serum neopterin levels in benign and malignant breast disease. Serum tryptophan and kynurenine levels and neopterin concentrations of 30 patients with malignant and 27 patients with benign breast disease were determined by HPLC and ELISA, respectively. The slight increase in tryptophan degradation in a subgroup of cancer patients with higher grade tumors was not statistically significant, but the increased degradation was correlated with higher neopterin concentrations. Neopterin levels in patients with malignant breast disease were significantly higher than in the benign group (p<0.05). Tryptophan degradation positively correlates with the aggressiveness of the tumor because it changes with tumor grade rather than disease stage.

Is neopterin level a predictive and differential biomarker in patients with thyroid disorders?

Neopterin production provides information about the extent of cellular immune activation. Measurement of neopterin levels may also provide predictive and prognostic information in patients with malignant thyroid diseases. In the present study, neopterin levels were investigated in patients with thyroid disorders (no.=68). Twenty-four patients had papillary thyroid cancers and the rest of them benign thyroid disorders. Results were compared with a healthy control group (no.=30). It was observed that there was a significant difference in neopterin levels between the control group and the thyroid disorders group (p<0.05). The mean neopterin levels in malignant and benign patients were also significantly different (p<0.05). Monitoring of urinary neopterin profile may be used in early diagnosis of papillary thyroid cancer. Neopterin seems to be a differential biomarker for malignant and benign thyroid disorders.

Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients

Echinococcus multilocularis causes alveolar echinococcosis which is a chronic, progressive zoonotic disease that mainly affects the liver. Hepatic alveolar echinococcosis is insidious and the patients are asymptomatic most of the time. Generally, it is incidentally found on imaging studies performed for other reasons. Specific symptoms may evolve if the vascular and biliary structures of the liver are affected. Hepatic alveolar echinococcosis shows a similar pattern to malignancies in terms of radiologic and clinical features. For this reason, oncological surgical principles should be applied during the resection of hepatic alveolar echinococcosis. The gold standard surgical treatment is resection with negative surgical margin. However, in patients whose radical resection is not possible other therapeutic options include palliative resection which has no benefit to the patient, and other curative major surgical options such as ex vivo liver resection, and autotransplantation and ultimately liver transplantation. The remnant liver volume has paramount importance if resection is going to be performed. For this reason, occasionally, remnant liver volume hypertrophy is induced by employing either two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy.

Effects of desflurane and isoflurane on hepatic and renal functions and coagulation profile during donor hepatectomy

We compared the effect of two inhalation anesthetics desflurane and isoflurane on postoperative hepatic and renal functions as well as coagulation profiles in living donors undergoing right hepatectomy. This study was performed on 80 patients who were randomly allocated to group D (desflurane, n = 40) or group I (isoflurane, n = 40) after Faculty Ethics Committee approval. After induction, isoflurane or desflurane was used with air/oxygen for anesthetic maintenance. The isoflurane or desflurane concentration was set at one minimum alveolar concentration (MAC). Remifentanil was infused for analgesia as well as cisatracurium. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), international normalized ratio (INR), albumin, total bilirubin, blood urea nitrogen, creatinine, platelet count, and hemoglobin levels were analyzed preoperatively at end of the operation, and on postoperative days (PODs) 1, 2, 3, 5, 7, and 30. Both AST and ALT differed significantly and continually except on POD 30. AST showed significant elevations from the end of the operation to POD 2 and ALT, from the end of the operation to POD 5 in group I compared with group D. INR was significantly higher from the end of the operation to POD 3 in group I and to POD 2 in group D. At the end of the operation as well as on POD 1 and POD 2, INR was significantly increased in group I compared with group D. Albumin level was significantly lower at the end of the operation in both groups, but it was not different. No patient developed hepatic or renal failure. Our study showed better postoperative hepatic tests and INR using desflurane than isoflurane at equivalent doses of 1 MAC in living donors undergoing right hepatectomy.

Hepatocellular Carcinoma Tumor Microenvironment and Its Implications in Terms of Anti-tumor Immunity: Future Perspectives for New Therapeutics

PURPOSE

Hepatocellular cancer is an insidious tumor that is often diagnosed in a later stage of life. The tumor microenvironment is the key to tumorigenesis and progression. Many cellular and non-cellular components orchestrate the intricate process of hepatocarcinogenesis. The most important feature of hepatocellular cancer is the immune evasion process. The present review aims to summarize the key components of the tumor microenvironment in the immune evasion process.

METHODS

Google Scholar and PubMed databases have been searched for the mesh terms "Hepatocellular carcinoma" or "Liver Cancer" and "microenvironment." The articles were reviewed and the components of the tumor microenvironment were summarized.

RESULTS

The tumor microenvironment is composed of tumor cells and non-tumoral stromal and immune cells. HCC tumor microenvironment supports aggressive tumor behavior, provides immune evasion, and is an obstacle for current immunotherapeutic strategies. The components of the tumor microenvironment are intratumoral macrophages (tumor-associated macrophages (TAM)), bone marrow-derived suppressor cells, tumor-associated neutrophils (TAN), fibroblasts in the tumor microenvironment, and the activated hepatic stellate cells.

CONCLUSION

There are intricate mechanisms that drive hepatocarcinogenesis. The tumor microenvironment is at the center of all the complex and diverse mechanisms. Effective and multistep immunotherapies should be developed to target different components of the tumor microenvironment.

Prognostic implications of intraoperative radiotherapy for unresectable pancreatic cancer

BACKGROUND/AIMS

To assess the prognostic effect of intraoperative radiotherapy (IORT) in unresectable pancreatic cancer.

METHODS

We reviewed 198 patients with unresectable pancreatic cancer, which was found during experimental laparotomy. Liver metastasis was observed in 70 patients, peritoneal metastasis in 44, liver and peritoneal metastasis in 23 and locally advanced tumor in 61. Treatment consisted of IORT with or without postoperative chemotherapy. Overall survival (OS) and prognostic factors were evaluated for each pattern of disease spread.

RESULTS

IORT was performed in 120 patients, and chemotherapy was administered in 80. Sixty patients did not receive either treatment. OS in the untreated group was significantly inferior to that for IORT alone and IORT plus gemcitabine (GEM)-based chemotherapy. IORT and GEM-based chemotherapy were identified as independent prognostic factors [hazard ratio (HR) = 0.51, p < 0.001; HR = 0.43, p < 0.001]. IORT was an independent prognostic determinant for patients with peritoneal metastasis (HR = 0.24, p = 0.011) but not for those with liver metastasis (HR = 0.78, p = 0.381).

CONCLUSION

IORT followed by GEM-based chemotherapy is the recommended treatment strategy in unresectable pancreatic cancer. and IAP.

Intraperitoneal rupture of the hydatid cyst disease: Single-center experience and literature review

BACKGROUND

The primary aim of this study was to present our experience on intraperitoneal rupture of the hydatid cyst in guidance of literature data.

METHODS

Demographical, clinical, radiological and postoperative follow-up data of 29 patients who underwent surgical treatment in our institution with an indication of intraperitoneal rupture of the hydatid cyst from January 2003 to July 2020 were analysed retropectively.

RESULTS

Among the 29 patients with an age range of from 16 to 79 years ( median= 39, IQR=25.5), 16 were male (55.2%) and 13 were female (44.8%). Intraperitoneal rupture of the hydatid cyst was spontaneous in 21 (72.4%), traumatic in 7 (24.13%) (2 of them were iatrogenic) and was due to shotgun in one patient. Vast majority of the patients were admitted to the emergency department in the first 24 hours after the onset of sign and symptoms. WBC varied from 8.600 to 30.900/mm3 (median=12.100, IQR=5.7). Ruptured cysts were localised in liver (n=25, 86.2%), in spleen (n=2, 6.89%) or in pelvis (n=2, 6.89%) and diameter varied from 40 to 200 mm (median= 90, IQR=50). Among the cysts ruptured in liver, 19 (76%) of them were localised in right lobe. Among the ruptured cysts of liver, 20 (80%) of them underwent conservative surgery (partial pericystectomy etc), remaining 5 patients (20%) underwent a radical surgical treatment (pericystectomy etc). A biliary orifice was diagnosed during surgical exploration in either cyst cavity or cut surface of liver in 12 (48%) of the patients. Patients with a dilated common bile duct or a visible biliary duct orifice in cystic cavity underwent common bile duct exploration and T-tube drainage procedure (n=6, 24%). One patient died on postoperative day one, due to cardiopulmonary complications secondary to cyst rupture. All along the postopeartive follow-up of median 1416 days, seven (24.1%) patients were diagnosed for diseased recurrence.

CONCLUSION

Intraperitoneal rupture of the hydatid cyst is a life-threatening complication of hydatid cyst disease, for which diagnosis without delay and timing of surgical treatment is essential. Anaphylactic shock cases require rapidly initiation of medical treatment against allergic reactions. Despite scolocidal agents, vesicular spread into peritoneal cavity account for the major risk factor for disease recurrence. Hence, abdominal cavity should be explored cautiously.

Current adjuvant therapeutic approaches for pancreatic cancer

Pancreatic cancer continues to be the fourth leading cause of death despite advancements in surgical and adjuvant therapeutic approaches. In the present review, the current cytotoxic therapeutic approaches and advanced targeted therapies are objectively discussed with consideration to the current literature.

Evaluation of gunshot wounds in the emergency department

BACKGROUND

This study aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications.

METHODS

A retrospective descriptive study was carried out including a total number of one hundred and forty-two patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Trauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients.

RESULTS

Among the one hundred and forty-two patients in the study, one hundred and twenty-eight (90.1%) were male. Mean age was 36 years. On admission, the average GCS score was 13, mean RTS was 6.64, median ISS was 5 and median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in three (13%) patients in FAST, whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (40%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; eighteen patients (75%) had isolated severe intracranial injuries, two (8.3%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower, and ISS were significantly higher than in surviving patients. Twenty three (95.8%) patients were in critical injury level (ISS 25-75, actually ISS >50) in the exitus group.

CONCLUSION

Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. Bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus, thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50, the mortality rate can be as high as 96%.