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Öğe A Case of Posterior Mediastinal Ganglioneuroma: The Importance of Preoperative Multiplanar Radiological Imaging(Galenos Publ House, 2013) Kizildag, Betul; Alar, Timucin; Karatag, Ozan; Kosar, Sule; Akman, Tarik; Cosar, MuratGanglioneuromas are mostly seen in adolescents and young adults and they are neurogenic tumors originating from sympathetic ganglions with a benign histology. Although ganglioneuromas are benign, the treatment is surgical as they can cause pain or compression symptoms, can be locally aggressive and can lead to cord compression. We present a young adult female with a ganglioneuroma of the right posterior mediastinum who presented with lower back pain, together with the clinical features, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) findings, differential diagnosis tips and their contribution to surgical planning.Öğe A case of spontaneous pneumomediastinum with unknown etiology(Derman Medical Publ, 2019) Alar, Timucin; Bayram, Ahmet Sami; Gedik, Ismail ErtugrulFirst described by Hamman in 1939, spontaneous pneumomediastinum (SPM) is a disease with the collection of air in the mediastinum without any underlying cause. It is usually seen in young males and its incidence is reported between 1/15000-1/25000 in different case series. We would like to present the case of a 16-year-old male patient who admitted to our hospital with the complaints of pleuritic chest pain and tenderness in the neck and was diagnosed as spontaneous pneumomediastinum. Patient spontaneously recovered without the need of an invasive procedure.Öğe A Rare Form of Mesothelioma: Malignant Pleural Deciduoid Mesothelioma(Aves, 2014) Alar, Timucin; Ozcelik, Cemal; Kilinc, Nihal; Yilmaz, UfukMesothelioma usually develops in elder male patients that are exposed to asbestos. Deciduoid mesothelioma is a rare variant of epithelioid mesothelioma and has a poorer prognosis than epithelioid mesothelioma. As this subtype was seen in the peritoneum of young females and its relation with asbestos was not definite, these lesions were formerly thought to be stimulated by endogenous hormones. In the subsequent years, a relation was established between this tumor and asbestos since it was seen in the pericardium and pleura of males. In this paper, we present a 64-year-old male patient with asbestos exposure, diagnosed as having malignant pleural deciduoid mesothelioma, in which a long survival was provided with chemotherapy after surgery.Öğe A Wandering Intravascular Scalpel Fragment After Lumbar Discectomy: A Case Report(Turkish Neurosurgical Soc, 2014) Aras, Adem Bozkurt; Ozkan, Omer Faruk; Alar, Timucin; Ozkan, Adile; Arik, M. Kasim; Kosar, Sule; Kirilmaz, BahadirVascular complications after lumbar discectomy are rarely seen. We present a unique and potentially life-threatening postoperative complication from this procedure. A 27-year-old man was admitted to our emergency vascular unit 1 day after a lumbar discectomy, during which a scalpel blade fragmented and a part was lost. Radiological images of the patient were performed and a broken scalpel blade was located anterior to the sacrum. An anterior laparotomy was performed which identified a mass within the left iliac vein that migrated suddenly to the inferior vena cava. An emergency angiography was performed, by which time the scalpel blade had ascended to the right-sided inferior pulmonary artery. It was subsequently removed via a right lateral thoracotomy.Öğe Clinical Picture, Radiological Findings, and Physical Examination in Tracheobronchial Foreign Body Aspiration: Which One is More Important?(Aves, 2013) Gedik, Ismail Ertugrul; Alar, Timucin; Omur, Dilek; Akdur, OkhanTracheobronchial foreign body aspiration is more frequent in children between 6 months-3 years of age, whereas it is seen less often in adults. The diagnosis of TBFB aspiration can be delayed in the adult population due to the lack of clinical suspicion. A case of a 56-year-old male patient admitted to the emergency department with a history of aspiration of a piece of carrot 4 hours previously, a cough and stridorous breathing is presented. His physical examination revealed reduced respiratory sounds in the lower zone of the left lung. There was no radiological clue of a tracheobronchial foreign body. Thus, we performed rigid bronchoscopy and found that the left lower lobe basal segment bronchus was almost totally obstructed by a foreign body (carrot) of 1.5x1 cm, which was removed. This was based on the clinical suspicion derived from the history and the physical examination alone. We emphasise that history and physical examination are more important in the diagnosis of organic or non-opaque tracheobronchial foreign body aspiration.Öğe Cutaneous Metastasis of Large Cell Lung Cancer: A Case Report(Derman Medical Publ, 2016) Gedik, Ismail Ertugrul; Alar, Timucin; Muratli, AshLung cancer has the highest incidence among all cancer types in the world. Skin is an uncommon organ that lung cancers metastasize and the incidence of cutaneous metastasis has been reported between 1-12%. In this report, we would like to present the case of a 67 year old male patient who admitted to our hospital with the complaint of multiple swollen masses on the different parts of his skin and has a homogenous mass with the width of 3 cm on chest x ray. The nodule at the intersection of the right 6th intercostal space and the mid-axillary line and with the dimensions of 1.5x1 cm was excised under local anesthesia and the specimen was sent to the pathology laboratory for histopathological examination. The diagnosis of large cell neuroendocrine carcinoma was made histopathologically. The patient was diagnosed as the distant metastasis of the large cell lung cancer, considered inoperable and referred to oncology clinics.Öğe Electrocardiographic changes in primary spontaneous pneumothorax(Baycinar Medical Publ-Baycinar Tibbi Yayincilik, 2014) Sevinc, Serpi; Kaya, Seyda Ors; Unsal, Saban; Koc, Sahbender; Alar, Timucin; Gunay, Samil; Boncu, MehmetBackground: This study aims to evaluate the electrocardiographic (ECG) changes in patients with primary spontaneous pneumothorax. Methods: A total of 48 patients (42 males, 6 females; mean age 29.7 +/- 12.5 years, range 15 to 58 years) with PSP were prospectively analyzed between November 2010 and November 2011. Pneumothorax size was calculated using the Rhea method. At least two standard 12-lead ECG were obtained for each patient (after the diagnosis of pneumothorax and prior to drain placement - ECG(pneumothorax), and after a complete re-expansion of the lung was achieved and confirmed radiologically - ECG(re-expanded)). P wave measurement, PR distance, QRS distance, QT interval and QT interval corrected for heart rate (QTc) were calculated. Heart rate (bpm), axis deviation measurement and the QRS amplitudes (QRSV1-6) in precordial leads were calculated. Results: There were 29 cases (60.4%) of left-sided and 19 cases (39.6%) of right-sided pneumothorax. The mean relative volume of pneumothorax was 43.0 +/- 21.5%. The most common symptoms included chest pain in 34 patients (70.8%) and dyspnea in 14 patients (29.2%). The pneumothorax duration was <= 24 hours in 30 patients (62.5%) and >24 hours in 18 patients (37.5%). There was a statistically significant difference between before and after the treatment for QT duration, axis deviation, heart rate, QRSV1, QRSV4, QRSV5 and QRSV6 (respectively; p=0.001, p=0.023, p=0.001, p=0.010, p=0.046, p=0.000, p=0.008). A total of seven patients had relevant QRS abnormalities including incomplete right bundle branch block in three patients, ST elevation in two patients and T-wave pointedness in one patient. Conclusion: Our study results suggest that left and right lung pneumothorax may cause axis variation, which is more pronounced in women, and that voltage increases after drainage in QRSV 4, 5 and 6 leads. In addition, pneumothorax may lead to specific ECG variations such as right bundle branch block and ST variations.Öğe Giant Mediastinal Mass: Thymolipoma(Lippincott Williams & Wilkins, 2011) Alar, Timucin; Ozcelik, Cemal; Klnc, NihalA 26-year-old man presented with shortness of breath on exertion that was gradually getting worse. His history revealed a mass in the left hemithorax that had been growing on follow-ups. Physical examination only showed that the respiratory sounds were fainter on the left. Thoracic computerized tomography was performed to elucidate the left hemithorax lesion seen on chest x-ray and a giant mass of lipid density extending from the anterior mediastinum to the diaphragm and filling almost the entire left hemithorax was observed. Total excision of the 25 x 21 x 8 cm mass weighing 1580 g was performed with a left thoracotomy. The histopathology investigation of the mass was reported as thymolipoma. The case was presented because it is a rare mediastinal mass.Öğe How does the type of thoracotomy affect the patient quality of life? A short form-36 health survey study(Springer, 2014) Alar, Timucin; Ceylan, Kenan Can; Kaya, Seyda Ors; Sevinc, Serpil; Sigirli, Deniz; Ozcelik, CemalWe evaluated whether the quality of life was affected in patients who had undergone various types of thoracotomy using the Short Form-36 Health Survey. The patients who had undergone thoracotomy for diagnosis or treatment between January and September 2011 in the Thoracic Surgery Department were investigated to determine the effect of the type of thoracotomy on the quality of life using the Short Form-36 Health Survey. The patients were classified into three groups. In Group I, the latissimus dorsi and the serratus anterior had both been preserved, and there was no muscle dissection, in Group II the latissimus dorsi muscle had been dissected and only the serratus anterior muscle has been preserved, and in Group III both muscles had been dissected, and the standard posterolateral muscle dissection had been performed. A total of 101 patients comprising 64 males (63.37 %) and 37 females (36.63 %), with a median age of 38 years, were included in this study. There were significant differences in all quality of life subscales between Groups I and III and between Groups II and III. The patients in Group I had the highest scores, while the patients in Group III had the lowest scores. There were no significant differences in five of the eight Short Form-36 subscales and one of the two summary scores values between Group I and Group II in females. We investigated the effect of the type of thoracotomy on the patient quality of life using the Short Form-36 Health Survey, and found that the standard posterolateral thoracotomy had a marked adverse effect on the quality of life compared to muscle-sparing thoracotomy. We also found that it is possible to use thoracotomy with serratus preservation rather than muscle-sparing thoracotomy in cases with benign diseases where a large field of view is required, such as for decortication and pulmonary hydatid cysts, without any significant decrease in the quality of life, especially in females.Öğe Is Acrylate Co-monomer (Glubran-2) Useful in the Prevention of Prolonged Air Leaks After Pulmonary Lobectomy?(Springer India, 2013) Alar, Timucin; Ceylan, Kenan Can; Duman, Elif; Usluer, Ozan; Basok, OktayMany synthetic materials are being used in order to reduce the frequency of prolonged air leak (PAL) in thoracic surgical practice. This study presents our experience with the topical application of acrylate co-monomer (Glubran-2) as a synthetic tissue adhesive in an attempt to decrease troublesome postoperative air leaks in patients undergoing resection for non-small cell lung carcinoma. Of the 112 patients who had undergone resection for lung carcinoma, 69 patients having lobectomy or bilobectomy were included in this study. The application group (group A) consisted of 33 patients where a synthetic tissue adhesive (Glubran-2) was used and compared with the control group (group C, n=36) retrospectively. There was no difference between the groups regarding demographic details and operative variables. Both groups were compared in view to PAL, chest tube duration, in-hospital stay and hospital costs. There was no significant difference between group A (n=11, 33 %) and group C (n=6, 17 %) for the development of PAL (P=0.11). Hospital stay was 16.1 +/- 6.7 days in group A and 15.3 +/- 5.8 days in group C (P=0.66). The surgical cost was significantly higher in group A (is an element of 806 +/- 127) than the group C (is an element of 624 +/- 94) (P<0.001). There was no significant difference between the groups regarding overall hospital costs (P=0.41). In this study, the use of Glubran-2 following lung resection for non-small cell lung carcinoma did not decrease the incidence of PAL. Neither did it have a favorable effect concerning in-hospital stay nor did it decrease overall hospital costs while increasing surgical costs as expected.Öğe Is it safe to work in a fast-food kitchen? a case of recurrent spontaneous pneumothorax with cholesterol granuloma(Baycinar Medical Publ-Baycinar Tibbi Yayincilik, 2015) Alar, Timucin; Muratli, Asli; Uludağ, Ahmet; Gedik, Ismail ErtugrulCholesterol granulomas are defined as cystic lesions containing cholesterol crystals surrounded by foreign body giant cells, fibrous tissue reaction and chronic inflammation. A 31-year-old male patient presented at the thoracic surgery outpatient clinic with a left apical recurrent pneumothorax. Bullectomy with multiple wedge resections was performed through a mini-thoracotomy. Histopathological examination of the resection material showed emphysematous lung and bullae + cholesterol granuloma. The patient had been working in a fast-food kitchen and at the french fries section, in particular, for nearly the past four years and had been exposed through inhalation to exogenous oil and oil products derived from vaporized vegetable and animal oil. We believe that staff working at a fast food kitchen and at the french fries section, in particular, should work using protective measures such as a mask and good ventilation.Öğe Lightning strike: a first case of unilateral diaphragmatic paralysis(Pagepress Publ, 2011) Alar, Timucin; Degirmenci, Yildiz; Karaman, Handan Isin OzisikLightning injury is the second most common cause of weather-related deaths in the United States. Despite the several neurological complications such as polyneuropathy, myelopathy, spinal cord injury, motor neuron disease due to the lightning-induced injury, there is no documented case of unilateral diaphragmatic paralysis. We describe the case of a patient with a history of lightning strike at childhood period, prior the onset of isolated, diaphragmatic paralysis, unilaterally. Clinical and electrophysiological findings suggest an injury restricted to the phrenic nerve, unilaterally.Öğe Lofgren's Syndrome: An Acute Variant of Sarcoidosis Diagnosed by Mediastinoscopy(Coll Physicians & Surgeons Pakistan, 2015) Alar, Timucin; Gunes, Fahri; MuratlE, Asli; Gedik, Ismail Ertugrul; Tekeli, Zeliha; Ukinc, KubilayLofgren's syndrome is an acute clinical form of sarcoidosis that is first described by Sven Lofgren as bilateral hilar lymphadenopathy together with Erythema Nodosum (EN) and accompanying arthritis/arthralgia. This syndrome has some differences in terms of treatment, prognosis and recurrence compared to sarcoidosis. In this report, we describe a 70 years old lady who admitted with multiple erythematous lesions and arthralgia of both lower extremities and she was diagnosed as Lofgren's syndrome via mediastinoscopy.Öğe One of the Thoracic Surgery Procedures: Mediastinoscopy(Bilimsel Tip Publishing House, 2010) Alar, TimucinObjective: Mediastinoscopy is a surgical procedure, developed and implemented today only by thoracic surgeon, which can be easily applied, with low morbidity and mortality, for diagnosis and treatment of lung diseases. Material and Method: In this study, 21 patients who underwent diagnostic standard cervical mediastinoscopy at the 3rd Thoracic Surgery Service in Antalya State Hospital between August 2004 and December 2007 were examined retrospectively. Results: The final diagnosis was obtained in 19 of 21 cases (90%). The most commonly detected disease was sarcoidosis in 8 cases (38%). In six (29%) patients in whom N2 disease were detected, unnecessary thoracotomy was avoided. There was no morbidity or mortality. Conclusion: Mediastinoscopy is a surgical procedure with low morbidity and mortality can be done easily except in advanced centers, with the detection of benign lesions and N2 disease can be reduce the workload of these centers.Öğe Pericardial Cysts: An Analysis of 12 Cases(Mary Ann Liebert Inc, 2011) Alar, Timucin; Bayram, Ahmet Sami; Gebitekin, CengizBackground: Pericardial cysts are usually asymtomatic, benign, congenital mediastinal lesions but may also be acquired after cardiothoracic surgery. The purpose of the study was to evaluate surgical approach and results of our experience with pericardial cysts. Patients and Methods: A total of 12 patients who had undergone surgical treatment for pericardial cyst between February 1999 and August 2010 were retrospectively evaluated. All patients were analyzed according to the symptoms, method for the diagnosis, cyst location, management, and outcomes. Results: The mean age was 50.4 +/- 17 years (range, 23-68 years) with a female-to-male ratio of 8:4. Pericardial cyst were located in the right hemithorax in 8 (67%) patients and left hemithorax in 4 (33%) patients. The cysts were resected by thoracotomy in 4 (33%) patients and by video-assisted thoracic surgery in 8 (67%) patients. There was an excellent long-term follow-up with no morbidity or mortality. Conclusion: Videothoracoscopic surgical removal of pericardial cysts is an excellent surgical intervention without serious morbidity and mortality.Öğe SHOULD COMPUTED TOMOGRAPHY BE THE FIRST CHOICE IN BLUNT CHEST TRAUMA?(Nobel Ilac, 2018) Bardakci, Okan; Akdur, Okhan; Karatag, Ozan; Akdur, Gokhan; Alar, Timucin; Beggi, HalilU Objective: We aimed to determine whether thorax tomography, which can be chosen as the first imaging method in blunt thoracic injuries early for and accurate diagnosis, has superiority to chest radiography. Material and Method: Patients who referred to Emergency Service between January 1st, 2011 and December 31st, 2013 with blunt chest trauma were evaluated. The examination was performed retrospectively. Results: 131 (75.3%) of blunt chest trauma patients were male. The mean age of the cases was 44.7 +/- 19.1. When trauma mechanisms leading to chest trauma were discussed, the most common cause of trauma in-vehicle was traffic accidents in 63 (36.2%) cases. There were 40 patients (28.5%) with normal radiography and pathologic findings in chest computed tomography. It was seen that costa fractures were the pathologies which escaped the attention most commonly in radiography and detected in computed tomography imaging in 27 (67%) of 40 cases. Pathologies not seen in radiography were pneumothorax in 12 cases (30%), hemothorax in 9 cases (22.5%) and sternum fracture in 3 cases (7.5%). Discussion: In conclusion, it would be useful to use thorax tomography as the primary imaging, especially in blunt chest trauma in emergency care, to be able to intervene quickly.Öğe Single-incision thoracoscopic surgery of pleural effusions for diagnosis and treatment(Springer, 2013) Alar, Timucin; Ozcelik, CemalSeveral procedures such as video-assisted thoracoscopic surgery (VATS) are used to make a definite diagnosis in recurrent pleural effusions so that appropriate treatment can be arranged. Single-incision thoracoscopic surgery (SITS) is the most appropriate procedure that can be used for this purpose. The contribution of SITS to diagnosis and treatment is evaluated in this study that we conducted using a single thoracoport in patients with pleural effusion. Nineteen consecutive patients with pleural effusion that was recurrent or refractory to medical treatment were included in the study to be diagnosed and treated with SITS. Thoracentesis was performed and pleural fluid samples obtained in all patients before the procedure. Pleural effusion drainage was performed from the 11-mm single skin incision by using a 10.5-mm single thoracoport, and biopsy or talc pleurodesis was performed in the same session when needed. The median age of the patients was 56.68 +/- A 3.05 years and there were 11 males and 8 females. The total amount of fluid drained by SITS was 1,436 +/- A 227 mL and the surgery lasted 81.05 +/- A 5.36 min. In addition, partial decortication and/or deloculation were performed in six patients and talc pleurodesis in nine patients. Fifteen patients were diagnosed with benign and four patients with malignant pleural effusion by thoracentesis, while nine patients were diagnosed with benign and ten patients with malignant pleural effusion by SITS. We therefore had six cases diagnosed as benign with thoracentesis who were diagnosed with malignant disease after SITS. SITS presents both diagnosis and treatment options together for pleural effusions. We believe SITS should be preferred to conventional three-port VATS to minimize the spread of infection and tumor cells to the chest wall in infectious and malignant diseases.Öğe The Analysis of the Chest Tube Thoracostomies Performed in a Newly Established Hospital of a Medical School(Derman Medical Publ, 2015) Alar, Timucin; Gedik, Ismail ErtugrulAim: We have analyzed the chest tube thoracostomies (CTT) performed in our Thoracic Surgery clinics of our newly established medical school hospital. Material and Method: The medical records of 130 patients to whom CTT were performed by the Thoracic Surgery Clinics of the Canakkale Onsekiz Mart University from December 2009 to July 2013 were retrospectively analyzed. Results: 102 patients (78%) out of 130 were male and 28 (22%) were women. Mean age of the patients were 58.9 +/- 20.4. 19% (n:25) of these patients were diagnosed at our clinics and the remaining 81% (n:105) were consultated from other clinics The most common indication of CTT was pleural effusion (35%, n:45). The mean fluid drainage of the patients with pleural effusions for various reasons (63%, n:84) were 1462.80 +/- 1054.46. The mean air drainage time for the patients with pneumothorax for various reasons (37%, n:46) were 5.8 +/- 3.1 days. There was only one complication (0,8%) in these 130 patients which was the intraparanchymal drain placement. Discussion: As a procedure that is usually performed under emergency conditions CTT has a high potential for development of serious complications and thus increasing the importance of resident doctor training in Thoracic Surgery clinics. CTT has a low rate of complications when performed with the right indication, at the appropriate location and in devotion to the surgical principles; can increase the importance of the Thoracic Surgeons in the medical centers that they are working at and can also increase the relationship of the Thoracic Surgery clinics with the other clinics.Öğe The effects of analgesic treatment and chest physiotherapy on the complications of the patients with rib fractures that arise from blunt chest trauma(Turkish Assoc Trauma Emergency Surgery, 2020) Alar, Timucin; Gedik, Ismail Ertugrul; Kara, MuratBACKGROUND: This prospective study aims to investigate the effect of chest physiotherapy and analgesic therapy on the possible complications of isolated rib fractures attributable to blunt thoracic trauma, such as hemothorax and pneumothorax. METHODS: Patients who presented to Canakkale Onsekiz Mart University School of Medicine Hospital's Emergency Department and Thoracic Surgery outpatient clinics within the first 24 hours of the post-traumatic period and did not have additional intrathoracic complications at presentation with blunt thoracic trauma and who were diagnosed with isolated rib fractures were enrolled in this prospective research study. The groups were designated as the patients who would receive analgesic treatment only (Group A) and the patients who would receive chest physiotherapy and analgesic treatment together (Group B). Patients who had first and second rib fractures or three or more rib fractures and who did not have additional organ injury were hospitalized in the Thoracic Surgery clinics; patients who had other organ trauma were hospitalized in related clinics. Patients were reassessed on their seventh and 30th post-traumatic days with physical examination and radiologic studies. RESULTS: The mean age of the 114 patients were 56.3 +/- 16.4 (22-87). There were 37 (32.5%) women and 77 (67.5%) men. Each group included 57 patients. The most common form of trauma was the same-level falls (31.6%). The mean number of rib fractures of all participants was 2.6 +/- 0.7 (1-10); the median number was 1.5. Fifty-two (45.6%) patients were hospitalized. The mean length of stay was 4.0 +/- 1.1 days. At the end of their treatment and follow-up periods, pleural effusion was found in 28 patients (24.6%) out of 114 enrolled at the side of trauma. Group B had a higher number of patients with pleural effusion (43.9%) than group A (5.3%). We performed tube thoracostomy in four patients, all of which were in group B (p<0.05). CONCLUSION: As a result of this study, chest physiotherapy maneuvers have increased the incidence of late hemothorax in patients with three or more isolated rib fractures. Also, minimal hemothoraces (<300 ml) may spontaneously regress, and no additional surgical treatment are required if the proper follow-up procedures are performed. It is advisable to hospitalize the blunt thoracic trauma patients who have three or more rib fractures and who are planned to undergo chest physiotherapy and or are prone to develop additional complications because of possible risks.Öğe The role of the tissue culture in granulomatous mediastinal clymphadenitis: Tuberculosis or not(Medical Association of Zenica-Doboj Canton, 2014) Sevinc, Serpil; Ors Kaya, Seyda; Unsal, Saban; Dereli, Sevket; Alar, Timucin; Can Ceylan, Kenan; Yucel, NurAim To evaluate the role of the tissue culture via mediastinoscopic biopsy in granulomatous mediastinal lymphadenitis. Methods The dossier data of 92 cases with mediastinal lymphadenitis showing granulomatous lymphadenitis features by cervical mediastinoscopy and whose clinical, radiological and bacteriological definitive diagnosis is tuberculosis and sarcoidosis were examined retrospectively. The rate of the positive tissue culture of mediastynoscopic biopsy in the diagnosis of granulomatous lymphadenitis was calculated. Results There were 65 (71%) females and 27 (29%) males. The mean age of the patients was 42.5 (range 15-75) years. Non necrotizing granulomatous lymphadenitis was detected in 58 (63 %) cases while necrotizing granulomatous lymphadenitis was seen in 34 (37%) cases. There were 29 cases diagnosed with tuberculosis. Acid resistant bacilli culture positive rate was 38% (in 11 cases). There were 21 (62%) cases of necrotizing granulomatous lymphadenitis and eight (14%) cases of non-necrotizing granulomatous lymphadenitis diagnosed with tuberculosis. Culture positivity was identified in two (25%) of eight cases whose differential diagnosis could not be made histopathologically as tuberculosis/sarcoidosis. Conclusions In addition to clinical, radiological and histopathological diagnosis, the study aims to highlight the importance of tissue culture in definitive diagnosis, especially undetermined incidents.
