The palliative management of non-islet cell tumour hypoglycaemia with glucocorticoids and somatostatin analogues in an unresectable hepatocellular carcinoma.

Non-islet cell tumour hypoglycaemia (NICTH) results from paraneoplastic insulin-like growth factor-II (IGF-II) secretion and its potent insulin-like effect. It causes recurrent, often severe, hypoglycaemic episodes, which is detrimental to quality of life. There is limited evidence regarding best supportive care in unresectable tumours. A 76-year-old woman presented with hypoglycaemic collapse. A new diagnosis of unresectable hepatocellular carcinoma (HCC) was made. The IGF-II:IGF-I ratio was 11.0, which confirmed NICTH. The octreoscan showed avid disease. The main problem was symptomatic nocturnal hypoglycaemia. Curative treatment options were not possible in this case and treatment focused on preventing symptomatic hypoglycaemia. Inpatient treatment was with high carbohydrate nasogastric (NG) feeds, prednisolone and somatostatin analogue (octreotide) infusion. Once stabilised, the patient was discharged with NG feeds, prednisolone and a long-acting somatostatin analogue (sandostatin). The patient received successful end-of-life care with her family as per her wishes, without requiring readmission. The treatments were well-tolerated and effective in preventing symptomatic hypoglycaemic episodes. The combination of high carbohydrate NG feed with prednisolone and somatostatin analogues was effective in preventing symptomatic hypoglycaemia. Somatostatin analogues had a useful steroid sparing role. Larger case series are warranted to clarify the management of NICTH patients with placebo-controlled studies to determine the role of somatostatin analogues.

Prediction, prevention and management of postresection liver failure.

BACKGROUND: Postresection liver failure (PLF) is the major cause of death following liver resection. However, there is no unified definition, the pathophysiology is understood poorly and there are few controlled trials to optimize its management. The aim of this review article is to present strategies to predict, prevent and manage PLF. METHODS: The Web of Science, MEDLINE, PubMed, Google Scholar and Cochrane Library databases were searched for studies using the terms 'liver resection', 'partial hepatectomy', 'liver dysfunction' and 'liver failure' for relevant studies from the 15 years preceding May 2011. Key papers published more than 15 years ago were included if more recent data were not available. Papers published in languages other than English were excluded. RESULTS: The incidence of PLF ranges from 0 to 13 per cent. The absence of a unified definition prevents direct comparison between studies. The major risk factors are the extent of resection and the presence of underlying parenchymal disease. Small-for-size syndrome, sepsis and ischaemia-reperfusion injury are key mechanisms in the pathophysiology of PLF. Jaundice is the most sensitive predictor of outcome. An evidence-based approach to the prevention and management of PLF is presented. CONCLUSION: PLF is the major cause of morbidity and mortality after liver resection. There is a need for a unified definition and improved strategies to treat it.

Surgeons and injury prevention: what you don't know can hurt you!

BACKGROUND: The most effective treatment for traumatic injuries is to prevent them from occurring. Currently, few surgeons receive any formal training in injury' control and prevention. This study was designed to test the knowledge of injury prevention principles among practicing surgeons, in order to identify areas in need of intensified educational efforts. STUDY DESIGN: Survey questions designed by members of the American College of Surgeons Committee on Trauma were programmed into a specialized touch-screen computer, which was displayed at four different surgery and trauma meetings, including the ACS Clinical Congress in 1999 and 2000. Participants were questioned about their knowledge of trauma epidemiology, bicycle helmet effectiveness, child safety seat usage, suicide, and domestic violence. RESULTS: Seventy-nine surveys were completed by surgeons, including 33 specializing in trauma care, and by 106 nurses attending trauma courses. Overall, the percentage of correct answers was 50%. There were no significant differences in survey scores between trauma surgeons and general surgeons, although both scored higher than trauma nurses. Areas where knowledge deficits were the most apparent included proper use of child safety seats, the effectiveness of airbags, the prevalence of suicide, and the annual cost of injury in America. CONCLUSIONS: The majority of practicing surgeons and nurses, including those working at trauma centers, are unaware of the basic concepts of injury prevention. Advancements in the field of injury control will require efforts to educate medical professionals and the public.

Nonoperative management of pediatric blunt hepatic trauma.

The purpose of this study was to examine the effect of operative versus nonoperative management of blunt hepatic trauma in children including transfusion practices. We reviewed the experience at our American College of Surgeons-verified Level I trauma center with pediatric commitment over a 5-year period. Children < or = 16 years of age suffering blunt liver injury as documented on admission CT scan were included in the study. Liver injuries identified on CT scan were classified according to the American Association for the Surgery of Trauma's Organ Injury Scaling system. All data are presented as mean +/- standard error. One case of pediatric liver trauma not identified on CT was excluded (prehospital cardiopulmonary resuscitation). Twenty-seven patients were included [age 9.3 +/- 1.0 years (range 3-16)]. Mechanisms of injury included motor vehicle crash (14), pedestrian struck by motor vehicle (7), bicycle crash (4), fall from height (1), and pedestrian struck by falling object (1). Trauma Score was 11.5 +/- 0.3. Distribution of Liver Injury Grade was as follows: grade I, 13; grade II, 9; grade III, 3; grade IV, 2; and grade V, 0. All five patients who underwent operative management had multiple organ injuries; three had concomitant splenic injury requiring operative repair; the remaining two had small bowel injury requiring repair. Hepatorrhaphy did not correlate with severity of liver injury: grade I, n = 1; II, n = 2; III, n = 1; and IV, n = 1. Three operated patients received blood transfusions. Twenty-two patients were managed with nonoperative treatment, of these only one required blood transfusion. No patients in the study died, three were transferred to subacute rehabilitation, one was transferred to another hospital, and 23 were discharged home. Our findings indicate that a majority of children with blunt hepatic injury as documented on CT scan can be managed with nonoperative treatment, and few require blood transfusions. Patients with multiple organ injury including simultaneous splenic injury are likely ideally managed through operative exploration and repair, whereas those with isolated liver injuries can be successfully managed nonoperatively.

Surgical residents' knowledge of injury prevention principles.

BACKGROUND: Injury prevention is not routinely taught in medical school or surgical residency curricula. Because of the integral role surgeons play in the diagnosis and treatment of trauma, we sought to determine the knowledge base of injury prevention concepts of surgical residents training in a state's level 1 trauma centers. METHODS: A written survey was given to general surgery residents at our state's three level 1 trauma centers. Twenty-one questions related to injury prevention were asked in addition to demographic data. Basic concepts of injury prevention, statistical knowledge of injury patterns, and knowledge of intentional violence were tested. RESULTS: Sixty-two residents completed the survey. Only 9 respondents reported prior formal instruction in injury prevention. Overall performance was (mean +/- SD) 10.6 +/- 2.5 of 31 possible points, for a mean average score of 34% correct answers. Postgraduate year level, prior medical school instruction in injury prevention or months of experience on a trauma service did not correlate with improved scores. Specific question performance ranged from 2% to 82% correct responses. Questions regarding domestic violence (60%), risk of burns (65%), and incidence of trauma deaths (82%) were answered correctly most often, while injury prevention theory questions, such as components of the Injury Prevention Triangle (5%), definition of YPLL (2%), and annual cost attributable to injury (19%) were least often answered correctly. CONCLUSIONS: These data indicate that general surgery residents are poorly educated regarding basic concepts of injury prevention. Importantly, a majority of respondents (69%) felt formal instruction in injury prevention should be included in their surgical residency curriculum.

Development and use of a prehospital-oriented EMS computer bulletin board service.

OBJECTIVE: To describe a Level 1 trauma center's response to the need for centralized information for EMS providers by implementing a computer bulletin board service (BBS). This service permits rapid retrieval of continuing education and reference information as well as an electronic forum for EMS-related issues. METHODS: A desktop computer with a modem supporting 14.4 kbps running Remote Access v2.01 is accessed by both local and toll-free telephone numbers. Users may connect using any personal computer or terminal equipped with a modem as no proprietary formats are used. The service is available 24 hours a day, free of charge, and requires users to register online. RESULTS: The first 41 months of experience has seen 9,592 calls answered by the BBS. 1,372 users, who may be individuals or groups, have registered on the service. Usage occurs in every county in the sponsor's state. In one sample period, 49% of the activity was educationally related, followed by discussion forums (26%). The BBS is used most heavily in the afternoon and evening hours. CONCLUSIONS: A prehospital-oriented EMS BBS has seen increasing utilization in its first 41 months of existence. It has rapidly established itself as a statewide mainstay of EMS information while being inexpensive to develop and maintain. It provides focused service to a target audience and is easily accessible. The development of similar local resources elsewhere is encouraged.

The hidden traps in decision making.

Bad decisions can often be traced back to the way the decisions were made--the alternatives were not clearly defined, the right information was not collected, the costs and benefits were not accurately weighed. But sometimes the fault lies not in the decision-making process but rather in the mind of the decision maker. The way the human brain works can sabotage the choices we make. Eight psychological traps that are particularly likely to affect the way we make business decisions are examined. The anchoring trap leads us to give disproportionate weight to the first information we receive. The status-quo trap biases us toward maintaining the current situation--even when better alternatives exist. The sunk-cost trap inclines us to perpetuate the mistakes of the past. The confirming-evidence trap leads us to seek out information supporting an existing predilection and to discount opposing information. The framing trap occurs when we misstate a problem, undermining the entire decision-making process. The overconfidence trap makes us over-estimate the accuracy of our forecasts. The prudence trap leads us to be overcautious when we make estimates about uncertain events. And the recallability trap leads us to give undue weight to recent, dramatic events. The best way to avoid all the traps is awareness--forewarned is forearmed. The authors show how to take action to ensure that important business decisions are sound and reliable.

Longitudinal analysis of the impact of a level 1 trauma center designation at a university hospital.

BACKGROUND: There have been no quantitative, longitudinal studies on the effect of Level 1 Trauma Center (TC) designation on a facility. The purpose of this study was to evaluate the impact of such designation. STUDY DESIGN: In September 1990, a 416-bed core affiliate hospital of the state medical school system was state-designated as the Level 1 TC for 6 counties. Data collected from five concurrent 1-year periods after TC designation included case number and acuity of condition, length of hospital and ICU stays, preventable death rates, financial coverage, and neurosurgery and orthopaedic volume. No registry data were available before TC designation. RESULTS: While the yearly number of cases remained stable, the overall severity of cases increased coincident with a 50% reduction in overtriage. The need for ICU services increased over 50%. Mean Injury Severity Score increased from 11.0 in year 1 to 13.8 in year 5. There was a 25% to 30% increase in severe neurosurgery injuries and in major orthopaedic trauma. There was no change in the "self-pay" financial category (12% to 16%) or the ratio of blunt to penetrating trauma (90:10). CONCLUSIONS: With Level 1 TC designation in a noninner city setting, planners can expect a shift to more severely injured patients, but should not expect an increase in nonpaying patients. Increases in severe injuries will continue to place strain on the ICU. Impact on neurosurgeons and orthopaedic surgeons mandates their support in TC planning.

Assessment of executive function in patients with mild traumatic brain injury.

BACKGROUND: The nature of functional deficit after mild traumatic brain injury (TBI) defined by Glasgow Coma Score of 13-15 is not fully described. This study explored the sensitivity of several neuropsychological tests to identify sequelae of mild traumatic brain injury (TBI). METHODS: Eleven adult patients with mild TBI admitted to a Level 1 trauma center were studied. The battery of tests included the Wechsler Intelligence Scale for Children -Revised: Mazes Subtest, Trails A and B, the Boston Naming Test, The Multilingual Aphasia Examination: Controlled Oral Word Association Test, and the Paced Auditory Serial Addition Task. RESULTS: Control subjects performed significantly better than patients with mild TBI on Trails A and B, the Controlled Oral Word Association Test, and Paced Auditory Serial Addition Task (subtests 2-4). No significant differences in performances between patients and controls was found for the Wechsler Intelligence Scale for Children -Revised: Mazes Subtest, Boston Naming Test, and Paced Auditory Serial Addition Task Subtest 1. CONCLUSION: The results suggest that tests of specific frontal lobe executive functions are valuable in diagnosing and monitoring recovery from mild TBI.

The hidden traps in decision making.

Bad decisions can often be traced back to the way the decisions were made--the alternatives were not clearly defined, the right information was not collected, the costs and benefits were not accurately weighted. But sometimes the fault lies not in the decision-making process but rather in the mind of the decision maker. The way the human brain works can sabotage the choices we make. John Hammond, Ralph Keeney, and Howard Raiffa examine eight psychological traps that are particularly likely to affect the way we make business decisions: The anchoring trap leads us to give disproportionate weight to the first information we receive. The statusquo trap biases us toward maintaining the current situation--even when better alternatives exist. The sunk-cost trap inclines us to perpetuate the mistakes of the past. The confirming-evidence trap leads us to seek out information supporting an existing predilection and to discount opposing information. The framing trap occurs when we misstate a problem, undermining the entire decision-making process. The overconfidence trap makes us overestimate the accuracy of our forecasts. The prudence trap leads us to be overcautious when we make estimates about uncertain events. And the recallability trap leads us to give undue weight to recent, dramatic events. The best way to avoid all the traps is awareness--forewarned is forearmed. But executives can also take other simple steps to protect themselves and their organizations from the various kinds of mental lapses. The authors show how to take action to ensure that important business decisions are sound and reliable.

Patient recall of therapeutic paralysis in a surgical critical care unit.

STUDY OBJECTIVE: To investigate patient recall of therapeutic paralysis (TP) in a surgical critical care unit. DESIGN: Prospectively applied structured interview of patients undergoing TP over 18 months. SETTING: Surgical critical care unit with 27 beds at a tertiary care university teaching hospital. PATIENTS: Forty patients admitted for postoperative care after coronary artery bypass graft surgery, trauma, or gastrointestinal surgery. INTERVENTIONS: Patients received TP and concurrent sedation with benzodiazepines, propofol, and narcotics. MEASUREMENTS AND MAIN RESULTS: After the end of TP patients were asked to recall the experience, and their responses were ranked on a four-point ordinal scale. Four of 11 patients recalled mostly negative events and experiences with TP, such as sleeplessness, discomfort, pain, anxiety, and inconsistent caregiver communication. All patients with recall experienced fear, anxiety, and sleeplessness. Single-drug therapy with propofol and inadequate benzodiazepine dosing were linked to patient recall. CONCLUSIONS: Patient recollection from TP may be more common than appreciated and is generally unpleasant. Adequate dosing with benzodiazepines and narcotics is warranted to prevent recall and discomfort.

Even swaps: a rational method for making trade-offs.

Making wise trade-offs is one of the most important and difficult challenges in decision making. Needless to say, the more alternative you're considering and the more objectives you're pursuing, the more trade-offs you'll need to make. The sheer volume of trade-offs, however, is not what makes decision making so hard. It's the fact that each objective has its own basis of comparison, from precise numbers (34% versus 38%) to relationships (high versus low) to descriptive terms (red versus blue). You're not just trading off apples and oranges; you're trading off apples and oranges and elephants. How do you make trade-offs when comparing widely disparate things? In the past, decision makers have relied mostly on instinct, common sense, and guesswork. They've lacked a clear, rational, and easy-to-use trade-off methodology. To help fill that gap, the authors have developed a system-which they call even swaps-that provides a practical way of making trade-offs among a range of objectives across a range of alternatives. The even-swap method will not make complex decisions easy; you'll still have to make hard choices about the values you set and the trades you make. What it does provide is a reliable mechanisms for making trades and a coherent framework in which to make them. By simplifying and codifying the mechanical elements of trade-offs, the even-swap method lets you focus all your mental energy on the most important work of decision making: deciding the real value to your company of different courses of action.

Air bags alone compared with the combination of mechanical restraints and air bags: implications for the emergency evaluation of crash victims.

BACKGROUND: Air bags (ABs) may be perceived by the public and physicians as protection for thoracoabdominal injuries. This study compares injury patterns when air bags are used alone with injury patterns when air bags plus mechanical restraints (MRs) are used. METHODS: Patients treated over a 4-year period with emergency medical services-documented AB deployment alone (n = 16) or AB plus MR (n = 22) were identified by trauma registry query. Medical records were reviewed and injuries recorded. RESULTS: Air bag-alone users had more severe overall (injury severity score > or = 15:9 vs 5), chest (abbreviated injury score [AIS] > or = 3:5 vs 1), and abdominal injuries (AIS > or = 3:6 vs 0). They required more tube thoracostomies (5 vs 0) and laparotomies (6 vs 0), longer hospitalizations (11.9 +/- 3.2 vs 5.3 +/- 1.4 days), and more intensive care unit admissions (8 vs 1). Craniofacial injuries (AIS > or = 3:6 vs 6) and fractures were similar. More victims using air bags alone required impatient rehabilitation and some patients died (6 vs 1). CONCLUSIONS: Crash victims using air bags alone (vs AB plus MR) had increased injury severity, hospitalizations, thoracoabdominal procedures, and rehabilitation. Physicians must be aware of the incomplete protection by air bags alone.

Cognitive trauma care is undervalued: adult splenic injury as a paradigm.

Nonoperative management (NOM) of adult splenic injury is evolving. Economic aspects of NOM have not been examined. We hypothesize that NOM reduces hospital and professional charges. Surgeon, radiologist, and hospital charges and reimbursements, and clinical outcome were obtained for 77 consecutive adult splenic injury patients (> or = 15 years old) over a 3-year period. NOM succeeded in 30 of 31 patients. NOM was associated with lower surgeon fee ($1,148 vs $4,452; P < 0.0001), surgeon reimbursement ($587 vs $2,773; P = 0.0001), and hospital charge ($18,982 vs $48,790; P = 0.001) relative to operative management. Radiologist fee ($1,776 vs $2,285) and reimbursement ($1,069 vs $1,537) were not significantly affected. No significant difference existed between surgeon (primary care provider) and radiologist reimbursement for NOM. ISS poorly correlated with economic variables. We conclude that cost reductions are another potential advantage of NOM. Surgeon reimbursement for the cognitive skills involved in NOM is minimal. Future health finance policy should recognize the cognitive aspects of trauma care.

Drugs for amnesia in the ICU.

OBJECTIVE: This review focuses on how patients' recall of their stay in the ICU can be modified pharmacologically. DATA SOURCES: Computerized MEDLINE and PAPERCHASE searches of English- and foreign-language published research from 1966 to 1995, bibliographies, pharmaceutical and personal files, and conference abstract reports. STUDY SELECTION: All abstracts from uncontrolled and controlled clinical trials were reviewed. DATA EXTRACTION: Study design, population, results, and safety information were retained. Efficacy conclusions were drawn from controlled trials. DATA SYNTHESIS: Patients without cerebral injury may recall mental and physical discomfort during their stay in the ICU. All benzodiazepines produce amnestic effects, but the short duration of action, lack of long-acting metabolites, and potent amnestic effects make lorazepam and midazolam preferable in this setting. Infusions of propofol for conscious sedation produce concentrations below those required for consistent amnesia. Opioids generally do not produce amnesia; however, end-organ failure and use of high doses of opioids may increase plasma concentrations to levels that produce impairment of learning and various degrees of amnesia. High infusion rates of ketamine may be required for satisfactory amnesia and pain control (with coadministration of benzodiazepine). Barbiturates and haloperidol do not impair memory in patients who are not critically ill. Antihistamines and anticholinergics that do not penetrate the central nervous system do not produce amnesia. Flumazenil may induce recall. CONCLUSIONS: Patients may remember their stay in the ICU, depending on the type of injury and the drug therapy. Of the drugs presented, benzodiazepines most reliably provide anterograde amnesia, whereas ketamine and propofol exhibit dose-dependent effects on memory.

Sternal fractures in blunt chest trauma: a practical algorithm for management.

A retrospective review of the medical records of blunt trauma patients with sternal fracture admitted to a level 1 trauma center from June 1990 to June 1993 was undertaken to determine the relationship between sternal fractures and clinically significant myocardial injury, and to assess the usefulness of cardiac evaluation and monitoring in these patients. Of 33 patients with sternal fracture, 31 were in motor vehicle crashes and 2 were pedestrians struck. All had Glasgow Coma Scale score = 15. No patient had a severe, life-threatening, associated injury (Abbreviated Injury Score of >3). No electrocardiogram or echocardiogram showed evidence of acute injury or ischemia. No arrhythmias requiring treatment were noted. No CPK-MB fraction was >5%. These results show that sternal fracture is not a marker for clinically significant myocardial injury. The management of sternal fracture patients should be directed toward the treatment of associated injuries.

Efficacy of prophylactic vena cava filters in high-risk trauma patients.

Severely injured trauma patients are at increased risk of pulmonary embolism (PE). Certain injuries may preclude the use of standard prophylactic measures, and even when used, these measures may be ineffective in the trauma population. We defined a group of trauma patients who are at statistically elevated risk of venous thromboembolic events. We then adopted an aggressive approach to the placement of prophylactic inferior vena cava (IVC) filters in these high-risk patients. Between January 1994 and January 1996 we treated 250 trauma patients who met our high-risk criteria. Prophylactic IVC filters were placed in 99 of these patients, and 151 received deep venous thrombosis prophylaxis with either heparin, sequential compression stockings, or a combination of these modalities. High-risk patients did not receive filters if they were unlikely to survive or showed rapid clinical improvement and were felt to not remain at high risk. The incidence of pulmonary embolism in this high-risk population was 1.6%. This is a significant reduction (p = 0.045, Fisher exact test) from the 4.8% incidence of PE in high-risk historical control patients with similar injury profiles. No patient with a prophylactic IVC filter suffered a clinically evident PE and there were no complications associated with placement of these filters. We conclude that the placement of prophylactic IVC filters in high-risk trauma patients is a safe and effective method of reducing the incidence of pulmonary embolism.

Peritoneoscintigraphy in the diagnosis of traumatic diaphragmatic rupture.

Current diagnostic modalities for traumatic diaphragmatic hernia (TDH) have limitations. Prior models differ from human injury. This study evaluates peritoneoscintigraphy in a rabbit model of TDH simulating human blunt injury. Ten adult New Zealand rabbits (two control, eight experimental) underwent tracheostomy and left thoracotomy under anesthesia. Experimental animals received a radial phrenotomy (1.0 to 3.5 cm). Incisions were closed over thoracostomy tubes, and ventilation was discontinued. Catheters were inserted intraperitoneally, and radiotracer in saline was injected. A gamma counter was used to take sequential images. Transdiaphraghmatic isotope was seen in only two animals. Both had large injuries; in one, the catheter was directed toward the diaphragmatic defect. We conclude that peritoneoscintigraphy is insensitive in the detection of TDH. It is unlikely to be an effective technique coupled with diagnostic peritoneal lavage. Further efforts to refine diagnostic capability for TDH should be directed elsewhere, such as laparoscopy.