Acute portal vein thrombosis in an isolated, blunt, minor liver injury near the porta hepatis.

Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 cm × 7 cm) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.

Combination of blood lactate level with assessment of blood consumption (ABC) scoring system: A more accurate predictor of massive transfusion requirement.

PURPOSE: Exsanguination is the most common leading cause of death in trauma patients. The massive transfusion (MT) protocol may influence therapeutic strategies and help provide blood components in timely manner. The assessment of blood consumption (ABC) score is a popular MT protocol but has low predictability. The lactate level is a good parameter to reflect poor tissue perfusion or shock states that can guide the management. This study aimed to modify the ABC scoring system by adding the lactate level for better prediction of MT. METHODS: The data were retrospectively collected from 165 trauma patients following the trauma activated criteria at Songklanagarind Hospital from January 2014 to December 2014. The ABC scoring system was applied in all patients. The patients who had an ABC score ≥2 as the cut point for MT were defined as the ABC group. All patients who had a score ≥2 with a lactate level >4 mmol/dL were defined as the ABC plus lactate level (ABC + L) group. The prediction for the requirement of massive blood transfusion was compared between the ABC and ABC + L groups. The ability of ABC and ABC + L groups to predict MT was estimated by the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 165 patients, 15 patients (9%) required massive blood transfusion. There were no significant differences in age, gender, mechanism of injury or initial vital signs between the MT group and the non-MT group. The group that required MT had a higher Injury Severity Score and mortality. The sensitivity and specificity of the ABC scoring system in our institution were low (81%, 34%, AUC 0.573). The sensitivity and specificity were significantly better in the ABC + L group (92%, 42%, AUC = 0.745). CONCLUSION: The ABC scoring system plus lactate increased the sensitivity and specificity compared with the ABC scoring system alone.

Clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing non-operative management.

BACKGROUND: Complications arising during non-operative management (NOM) of blunt hepatic and/or splenic trauma, particularly in cases of severe injury, are associated with significant morbidity and mortality. Abdominal computed tomography (CT) is the gold standard for the initial detection of complications during NOM. Although many institutions advocate routine in-hospital follow-up scans to improve success rates, others recommend a more selective approach. The use of follow-up CT remains a subject of ongoing debate, with no validated guidelines available regarding the timing, effectiveness, or intervals of follow-up imaging. OBJECTIVE: We aimed to identify the clinical parameters for the early detection of complications in patients with blunt hepatic and/or splenic injury undergoing NOM. MATERIALS AND METHODS: This retrospective cohort study included patients with blunt hepatic and/or splenic trauma treated at Songklanagarind Hospital, a level 1 trauma center, from 2013 to 2022. We assessed all patients indicated for non-operative management and examined their clinical parameters and complications. RESULTS: Of 542 patients with blunt hepatic and/or splenic injuries, 315 (58%) were managed non-operatively. High-grade hepatic injuries were significantly associated with complications, as determined through a multivariate logistic regression analysis after adjusting for factors such as contrast blush findings, age, sex, and injury severity score (ISS) (adjusted OR = 7.69, 95% CI 1.59-37.13; p = 0.011). Among the patients with complications (n = 27), 17 (63%) successfully underwent non-operative management. Notably, eight patients presented with clinical symptoms prior to the diagnosis of complications, while only two patients had no clinical symptoms before the diagnosis. Tachycardia, abdominal pain, decreased hematocrit levels, and fever were significant indicators of complications (p < 0.05). CONCLUSION: Routine CT to detect complications may not be necessary in patients with asymptomatic low-grade blunt hepatic injuries. By contrast, in those with isolated blunt hepatic injuries that are managed non-operatively, high-grade injuries, the presence of a contrast blush on initial imaging, and the patient's age may warrant consideration for routine follow-up CT scans. Clinical symptoms and laboratory observations during NOM, such as tachycardia, abdominal pain, decreased hematocrit levels, and fever, are significantly associated with complications. These symptoms necessitate further management, regardless of the initial injury severity, in patients with blunt hepatic and/or splenic injuries undergoing NOM.

Scapular fractures and concomitant injuries.

OBJECTIVE: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized. Few studies have investigated this presumed association. In this study, we investigated the incidence of significant associated injuries with scapular fracture and their outcomes. METHODS: A retrospective study was conducted from 2005 to 2009 in a level I trauma center in Thailand. All blunt trauma patients were identified. Patients?demographics, injury mechanism, associated injuries, Injury Severity Score (ISS), and survival outcomes were recorded. The management of associated injuries with scapular fracture was reviewed, and the risk factors for mortality were identified. RESULTS: Among the 7 345 trauma patients admitted, scapular fractures occurred in 84 cases (1.1%). The mean age was (37.98+/-15.21) years. Motorcycle crash was the most frequent mechanism of injury, occurring in 51 cases (60.7%). Seventy-four patients (88.1%) suffering from scapular fractures had associated injuries: 5 (6.0%) had significant chest injuries, but none of them had blunt thoracic aortic injury. Two patients (2.4%) with scapular fractures died. Factors determining the likelihood of mortality were: (1) ISS larger than 25 (LR equal to 8.5, P less than 0.05); (2) significant associated chest injury (AIS larger than 3, LR equal to 5.3, P less than 0.05) and (3) significant associated abdominal injury (AIS larger than 3, LR equal to 5.3, P larger than 0.05). CONCLUSION: A blunt scapular fracture may not accompany a blunt thoracic aortic injury but it is strongly related to other injuries like chest injury, extremity injury, head injury, etc. If a scapular fracture is found with a high ISS score, high chest or abdomen AIS score, the patient would have a high risk of mortality.

Age as the Impact on Mortality Rate in Trauma Patients.

Background: Globally, the fastest-growing population is that of older adults. Geriatric trauma patients pose a unique challenge to trauma teams because the aging process reduces their physiologic reserve. To date, no agreed-upon definition exists for the geriatric trauma patients, and the appropriate age cut point to consider patients at increased risk of mortality is unclear. Objectives: To determine the age cut point at which age impacts the mortality rate in trauma patients in Thailand. Materials and Methods: This was a retrospective cohort and prognostic analysis study conducted in trauma patients ≥40 years. Patient data were retrieved from the trauma registry database and hospital information system in Songklanagarind Hospital. The estimated sample size of 1,509 patients was calculated based on the trauma registry data. The age with the maximum mortality rate was used as the cut point to define the elderly population. Hospital cost, intensive care unit (ICU) length of stay, gender, precomorbidity, mechanism of injury, injury severity score (ISS), and trauma and injury severity score were analyzed for any correlation with mortality, and whether or not they were associated with elderly trauma patients. Results: A total of 1,523 trauma patients ≥40 years were included in the study. The median age in both the survival and death groups was 61 years, with gender in both groups being similar (p value = 0.259). In the multivariate logistic regression analyses, the adjusted odds ratio (OR) showed that increasing age was significantly associated with mortality (OR = 1.05; 95% CI, 1.02-1.07; p value <0.001). In the age group of 70 to 79 years and >80 years, the odds of mortality were significantly increased (OR 3.29, 95% CI, 1.24-8.68; p value = 0.016 and OR 3.29, 95% CI, 1.27-12.24; p value = 0.018, respectively). Conclusion: Age is a significant risk factor for mortality in trauma patients. The mortality significantly increased at the age of 70 and higher.

Massive Blood Transfusion for Trauma Score to Predict Massive Blood Transfusion in Trauma.

BACKGROUND: Massive blood loss is the most common cause of immediate death in trauma. A massive blood transfusion (MBT) score is a prediction tool to activate blood banks to prepare blood products. The previously published scoring systems were mostly developed from settings that had mature prehospital systems which may lead to a failure to validate in settings with immature prehospital systems. This research aimed to develop a massive blood transfusion for trauma (MBTT) score that is able to predict MBT in settings that have immature prehospital care. METHODS: This study was a retrospective cohort that collected data from trauma patients who met the trauma team activation criteria. The predicting parameters included in the analysis were retrieved from the history, physical examination, and initial laboratory results. The significant parameters from a multivariable analysis were used to develop a clinical scoring system. The discrimination was evaluated by the area under a receiver operating characteristic (AuROC) curve. The calibration was demonstrated with Hosmer-Lemeshow goodness of fit, and an internal validation was done. RESULTS: Among 867 patients, 102 (11.8%) patients received MBT. Four factors were associated with MBT: a score of 3 for age ≥60 years; 2.5 for base excess ≤-10 mEq/L; 2 for lactate >4 mmol/L; and 1 for heart rate ≥105 /min. The AuROC was 0.85 (95% CI: 0.78-0.91). At the cut point of ≥4, the positive likelihood ratio of the score was 6.72 (95% CI: 4.7-9.6, p < 0.001), the sensitivity was 63.6%, and the specificity was 90.5%. Internal validation with bootstrap replications had an AuROC of 0.83 (95% CI: 0.75-0.91). CONCLUSIONS: The MBTT score has good discrimination to predict MBT with simple and rapidly obtainable parameters.

Multidisciplinary management of a penetrating cerebellar injury by a fishing speargun: A case study and literature review.

BACKGROUND: Fishing spearguns are a rare cause of nonmissile penetrating brain injuries (PBIs). Discussion of their injury patterns and treatments has been published only sporadically. Here, we report a case of a self-inflicted PBI caused by this type of weapon and present an extensive review of previous case reports to help ascertain the appropriate surgical approach. CASE DESCRIPTION: A 26-year-old man with a preexisting psychiatric illness was transferred to our hospital after a self-inflicted shot with a fishing speargun through his mouth. The ensuing injuries included the impalement of a spear intracranially through the soft palate and posterior oropharyngeal wall. The spear was surgically accessed by the otolaryngology team by splitting the soft palate and was removed by the neurosurgery team in the retrograde direction. Cerebral angiographies were done pre- and postoperatively, and these did not detect any vertebrobasilar arterial system injuries. The patient's postoperative care was uneventful, and he was followed up by a psychiatrist for his long-term care. CONCLUSION: This example of a complicated case of nonmissile PBI caused by an uncommon type of weapon shows how this type of medical emergency can be managed successfully with effective teamwork using a multidisciplinary approach.

Correlation between Maximum Clot Firmness in FIBTEM and Fibrinogen Level in Critical Trauma Patients.

BACKGROUND: Both fibrinogen level and rotational thromboelastometry (ROTEM®) are accurate tests to demonstrate a bleeding tendency. FIBTEM® is one type of ROTEM test to determine the function of fibrinogen. An advantage of FIBTEM is helping physicians make proper decisions for blood component transfusions. However, the correlation between fibrinogen level and FIBTEM is still unclear. OBJECTIVE: The aim of this study was to demonstrate a correlation between maximum clot firmness (MCF) in FIBTEM and fibrinogen level in critical trauma patients. METHODS: Data were retrospectively collected from 87 patients who visited the emergency department between May 2017 and January 2019 in Songklanagarind Hospital. Blood specimens were sent for both ROTEM evaluation and fibrinogen level. The data were analysed with STATA program version 12.1. RESULTS: Eighty-seven patients were enrolled in the study over the 21-month period. The patients consisted of 73 males (83.9%) with a median age of 40 years. Seventy-three patients (83.9%) were still alive. The following equation from FIBTEM MCF was used to predict fibrinogen level: fibrinogen level = 138 + (15.2 × FIBTEM MCF) (Lin's concordance correlation coefficient of 0.52, P < 0.001). The results showed a good correlation of FIBTEM MCF to predict patients with hypofibrinogenemia (area under ROC curve = 0.81). Patients with normal fibrinogen levels received significantly fewer units of all types of blood components. CONCLUSION: FIBTEM MCF had poor prediction of fibrinogen level; however, it can help to identify patients who have hypofibrinogenemia.

Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study.

HYPOTHESIS: The use of liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS: All patients admitted following blunt multisystem trauma. INTERVENTION: Pan scan, including computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis, with the following inclusion criteria: (1) no visible evidence of chest or abdominal injury, (2) hemodynamically stable, (3) normal abdominal examination results in a neurologically intact patient or unevaluable abdominal examination results secondary to a depressed level of consciousness, and (4) significant mechanisms of injury. Radiological findings and changes in treatment based on these findings were recorded. MAIN OUTCOME MEASURE: Any alteration in the normal treatment plan as a direct result of CT scan findings. These alterations include early hospital discharge, admission for observation, operative intervention, and additional diagnostic studies or interventions. RESULTS: One thousand patients underwent pan scan during the 18-month observation period, of which 592 were evaluable patients with no obvious signs of abdominal injury. Clinically significant abnormalities were found in 3.5% of head CT scans, 5.1% of cervical spine CT scans, 19.6% of chest CT scans, and 7.1% of abdominal CT scans. Overall treatment was changed in 18.9% of patients based on abnormal CT scan findings. CONCLUSIONS: The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.

Use of computed tomography in anterior abdominal stab wounds: results of a prospective study.

HYPOTHESIS: Computed tomography (CT) can be used to evaluate patients with anterior abdominal stab wounds (AASWs). DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS AND METHODS: All of the patients sustaining AASWs, excluding those with hemodynamic instability, peritonitis, or omental evisceration, were admitted for serial abdominal examinations with or without CT depending on attending preference. Patients with associated left thoracoabdominal stab wounds underwent diagnostic laparoscopy. MAIN OUTCOME MEASURES: Change in patient management as a direct result of the CT scan findings, as well as sensitivity, specificity, positive predictive value, and negative predictive value of CT scanning calculated against clinical outcome (the need for laparotomy, uneventful discharge without laparotomy, or return to the hospital for adverse events). RESULTS: One hundred fifty-six consecutive patients with AASWs were included over 24 months. Computed tomography was performed for 67 patients (CT group) whereas 89 patients were admitted for serial examination only (no-CT group). Nineteen of the 67 patients in the CT group had positive CT results, leading to laparotomy in 10 patients. Of the 48 patients with negative CT results, 3 underwent diagnostic laparoscopy for an associated thoracoabdominal stab wound and 2 eventually underwent laparotomy for clinical deterioration with negative results. Excluding patients with associated thoracoabdominal stab wounds, the negative predictive value of CT was 100%. CONCLUSIONS: In patients with AASWs, CT can be used to identify visceral injuries. It is a promising tool that may identify patients who can be discharged after a shorter period of observation. Further evaluation of its use in patients with AASWs is warranted.

Acute respiratory distress syndrome in the trauma intensive care unit: Morbid but not mortal.

HYPOTHESIS: The diagnosis of acute respiratory distress syndrome (ARDS) carries significant additional morbidity and mortality among critically injured patients. DESIGN: Retrospective case-control study using a prospectively maintained ARDS database. SETTING: Surgical intensive care unit (ICU) in an academic county hospital. PATIENTS: All trauma patients admitted to the ICU from January 1, 2000, to December 31, 2003, who developed ARDS as defined by (1) acute onset, (2) a partial pressure of arterial oxygen-fraction of inspired oxygen ratio of 200 or less, (3) bilateral pulmonary infiltrates on chest radiographs, and (4) absence of left-sided heart failure. Each patient with ARDS was matched with 2 control patients without ARDS on the basis of sex, age (+/-5 years), mechanism of injury (blunt or penetrating), Injury Severity Score (+/-3), and chest Abbreviated Injury Score (+/-1). MAIN OUTCOME MEASURES: Mortality, hospital charges, hospital and ICU lengths of stay, and complications (defined as pneumonia, deep venous thrombosis, pulmonary embolism, acute renal failure, and disseminated intravascular coagulopathy). RESULTS: Of 2042 trauma ICU admissions, 216 patients (10.6%) met criteria for ARDS. We identified 432 similarly injured control patients. Compared with controls, trauma patients with ARDS had more complications (43.1% vs 9.5%), longer hospital (32.2 vs 17.9 days) and ICU (22.1 vs 8.4 days) lengths of stay, and higher hospital charges (267,037 dollars vs 136,680 dollars) (P < .01 for all), but mortality was similar (27.8% vs 25.0%, P = .48). CONCLUSION: Although ARDS is associated with increased morbidity, hospital and ICU length of stay, and costs, it does not increase overall mortality among critically ill trauma patients.

Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank.

BACKGROUND: Blunt renal artery injuries are rare and no single trauma center can accumulate substantial experience for meaningful conclusions about optimal therapeutic strategies. The purpose of this study was to assess the incidence of renal artery injuries after different types of blunt trauma, and evaluate the current therapeutic approaches practiced by American trauma surgeons and the effect of various therapeutic modalities on hospital outcomes. STUDY DESIGN: This was a National Trauma Data Bank study including all blunt trauma admissions with renal artery injuries. Demographics, mechanism of injury, Injury Severity Score, Abbreviated Injury Score for each body area (head, chest, abdomen, extremities) injuries, type of management (nephrectomy, arterial reconstruction, or observation), time from admission to definitive treatment, and hospital outcomes (mortality, ICU, and hospital stay) were analyzed. Multiple and logistic regression analyses were used to examine the relationship between type of management and hospital outcomes. RESULTS: Of a total of 945,326 blunt trauma admissions, 517 patients (0.05%) had injuries to the renal artery. Of the 517 patients, the kidney was not explored in 376 (73%), 95 (18%) patients had immediate nephrectomy, and 45 (9%) patients underwent surgical revascularization. In 87 of 517 (17%) patients, renal artery injury was the only intraabdominal injury. Of the 87 patients with isolated renal artery injuries, 73 (84%) were observed, 7 (8%) underwent surgical revascularization, and 7 (8%) had early nephrectomy. Multiple regression analysis demonstrated that patients who had surgical revascularization had a considerably longer ICU and hospital stay than observed patients. Patients who had nephrectomy had a considerably longer hospital stay than observed patients. CONCLUSIONS: Blunt renal artery injury is rare. Nonoperative management should be considered as an acceptable therapeutic option.

Hemodynamically "stable" patients with peritonitis after penetrating abdominal trauma: identifying those who are bleeding.

HYPOTHESIS: Despite initial presentation, hemodynamically stable patients with penetrating abdominal trauma may have significant ongoing hemorrhage and major intra-abdominal injuries requiring emergent surgical intervention. DESIGN: Cohort analytic study. SETTING: Academic, level I trauma center. PATIENTS: One hundred thirty-nine consecutive hemodynamically stable patients with penetrating abdominal trauma in whom peritonitis was the sole indication for laparotomy. MAIN OUTCOME MEASURES: The primary outcome was the amount of blood initially found at laparotomy. Secondary outcomes included additional intraoperative blood loss, intraoperative hypotension, transfusion, fluid, and vasopressor requirement; need for admission to the intensive care unit and mechanical ventilation; complications; survivor length of stay in the hospital and intensive care unit; and mortality. RESULTS: The admission systolic blood pressure (mean +/- SD, 131 +/- 22 mm Hg) and heart rate (mean +/- SD, 91 +/- 22 beats/min) were normal. Median time from peritonitis to incision was 40 minutes. Ninety-seven percent of patients had intra-abdominal injury, including 81%, hollow visceral; 36%, solid organ; and 11%, vascular injury. Though most patients had less than 750 mL(3) of blood found initially at laparotomy, there were 11% with 750 to 1500 mL(3) and 7% with 1500 mL(3) or more. Intraoperative hypotension (25%) and blood transfusion (39%) were common. Postoperatively, 40% of patients required intensive care (78% of them requiring mechanical ventilation) and 19% required additional transfusion within 24 hours. Complications occurred in 25% of patients, with intra-abdominal abscess (12%) and wound infection (7%) being the most common. Three patients died, 2 of exsanguination and 1 of multisystem organ failure. CONCLUSIONS: Following penetrating abdominal trauma, peritonitis should be a trigger for emergent operation regardless of vital signs, because hemodynamic "stability" does not reliably exclude significant hemorrhage. Vascular injury, subsequent hypotension, blood transfusion, and complicated postoperative course are common in this population.

Rotational thromboelastometry in the diagnosis of coagulopathy in major pediatric surgical operations.

OBJECTIVES: To examine the correlation between rotational thromboelastometry (ROTEM) and coagulopathy after major pediatric surgical operations. METHODS: From November 2013 until April 2015, pediatric cases who underwent major noncardiac surgeries and met the coagulopathy-risk criteria were reviewed for postoperative clinically significant coagulopathy (CSC). Two ROTEM studies, EXTEM and INTEM, were performed at the immediately postoperatively without the results being taken into any clinical decision making. RESULTS: Seventy-seven operations on 73 patients were included in this analysis. CSC occurred following 24 operations (32%) with a significantly higher incidence when a patient had a higher coagulopathy risk. On univariate analysis, evidence of diffuse bleeding in the operative field and massive bleeding were the 2 parameters with the strongest association with CSC. INTEM and EXTEM had specificities in diagnosing CSC of 75.5% and 94.3%, respectively. When each individual EXTEM and INTEM item was analyzed against CSC using ROC analysis, clot forming time (CFT) gave the largest under the curve area. The cut-off CFTs that gave the highest sensitivity and specificity in this study were 120seconds for EXTEM and 100seconds for INTEM. CONCLUSION: Postoperative coagulopathy is a risk that should always be considered in pediatric surgical operations. Thromboelastometry can be a hemostatic test providing high predictive value for this condition.

Results of gastric pull-up reconstruction for pharyngolaryngo-oesophagectomy in advanced head and neck cancer and cervical oesophageal squamous cell carcinoma.

OBJECTIVE: To study long-term clinical swallowing function and survival outcome in head and neck and cervical oesophageal cancer patients who underwent pharyngolaryngo-oesophagectomy (PLE). METHODS: The clinical data of 48 patients who were treated with PLE were analysed. All patients had advanced disease, so the construction required a transposed stomach. Body weight and clinical swallowing function were evaluated postoperatively. The swallowing function was assessed at an interview concerning food ingestion and regurgitation. The survival group was studied using a Kaplan-Meier survival curve. RESULTS: Forty-one cases of hypopharyngeal cancer and four cases of cervical oesophageal cancer were studied. In three cases (6%), hypopharyngeal and thoracic oesophageal squamous cell carcinoma occurred together. Most cases had good-to-fair results. The average body weight gain was increased after surgery. There was one hospital death. The most common complications were pulmonary (4%). Median survival was 27 months. CONCLUSION: A pharyngogastric anastomosis after PLE can be performed with low morbidity and good swallowing function.

Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients.

BACKGROUND: Although there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores. METHODS: A retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa. RESULTS: A total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed. CONCLUSIONS: The use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.

Obesity and traumatic brain injury.

BACKGROUND: As obesity continues to run rampant in our society, an understanding of its adverse effect after traumatic injury is starting to unfold. We hypothesize that obesity negatively impacts head-injured patients, and the current study intends to compare obese and lean patients with traumatic brain injury (TBI). METHODS: This is a retrospective study evaluating all blunt trauma patients with TBI admitted to the intensive care unit (ICU) in our urban, Level I trauma center from 1998 until 2003. Body mass index (BMI) was used to categorize patients as either lean (BMI <30 kg/m2) or obese (BMI > or =30 kg/m2). Admission demographics, type and severity of head injury, and associated injuries were recorded for each patient. Primary outcome was mortality, while secondary outcomes were cause of death, complications, and for survivors, days of mechanical ventilation, ICU length of stay, and hospital length of stay. Obese and lean patients were compared using univariate analysis and multivariate stepwise logistic regression. In addition, a subgroup analysis of patients with isolated head injury was performed. RESULTS: There were 690 patients with TBI admitted to the ICU during the study period, with 129 (19%) obese patients (BMI = 34 +/- 5 kg/m2) and 561 (81%) lean patients (BMI = 24 +/- 4 kg/m2). The two groups were similar with the exceptions that obese patients were older (46 +/- 20 years versus 39 +/- years, p < 0.01), had lower admission systolic blood pressure (125 +/- 38 mm Hg versus 134 +/- 30 mm Hg, p = 0.01), and more often sustained an associated chest injury (46% versus 35%, p = 0.03). Obese patients with TBI had a trend toward more complications (34% versus 28%, p = 0.17) and a higher mortality (36% versus 25%, p = 0.02). However, stepwise logistic regression failed to identify obesity as an independent risk factor for either morbidity or mortality. In addition, obese patients with isolated head injury had no increase in complications or death. CONCLUSIONS: Although obese patients suffer more complications and higher mortality than lean patients after TBI, this adverse effect seems to be due to age, lower admission blood pressure, and more associated chest injury, rather than a direct result of the obese state.

Mutations and polymorphisms of Hirschsprung disease candidate genes in Thai patients.

Mutation and polymorphism data for Hirschsprung disease (HSCR) varies among ethnic groups. Single nucleotide polymorphisms (SNP) of RET proto-oncogene (RET) were recently shown to be associated with the disease, and with disease severity, in different populations. In this study, comprehensive analysis of RET, GDNF, EDNRB, ET-3, and SOX-10 genes among sporadic HSCR in Thailand was conducted by standard PCR-SSCP, RFLP, and sequencing methods. Of 41 patients, 30 cases had rectosigmoid disease (RSD) and 11 cases were assigned to the long-segment disease (LSD) group. Four missense mutations of RET, S100M, R231H, T278N, and G533S, were identified in three patients. One novel missense mutation, V111Q, was detected in EDNRB. For ET-3, two novel missense mutations, D166E and C173R, occurred concomitantly in a patient. The incidence of missense mutation was significantly higher in our female HSCR patient than in the male counterpart. Statistical analysis of the SNPs revealed a significant difference between allele distribution of RET L769L in patients in the LSD and RSD groups. The predominant genotype construct of RET A45A/L769L in our HSCR was GG/GG, which is obviously different from results from all previous studies. The GG/GG genotype construct was associated with RSD and with males. The study also detected a variant allele of RET S836S which has never been reported in Asian cohorts.

Near-hanging injuries: a 10-year experience.

OBJECTIVE: To review the injury patterns and analyse outcomes in patients who present after near-hanging. METHODS: This is a trauma registry study that included all patients who were admitted to an academic Level I trauma centre with the diagnosis of attempted suicide by hanging between January 1993 and December 2003. All patients who were dead on arrival or in cardiopulmonary arrest were excluded. Data regarding demographics, injuries, and outcomes were examined. Independent risk factors for poor outcome were identified. RESULTS: During the 10-year study period, 63 patients were admitted after near-hanging. A total of 12 patients (19%) had 17 injuries. Cervical spine fractures occurred in nearly 5% of cases. Four factors were found to be significantly associated with poor outcome: systolic blood pressure <90, Glasgow coma score < or =8, anoxic brain injury on computed tomography (CT) scan, and injury severity score >15. However, logistic regression analysis found only anoxia on CT scan to be independently associated with poor outcome (p < 0.01). CONCLUSION: Injuries commonly occurred after near-hanging. Liberal screening using CT scans is warranted. The prognosis is favorable, even with patients who arrive with a GCS < or =8. Overall survival was 90% and only 3.5% were discharged with severe or permanent disability.