Lateral sellar angiolipomas: a therapeutic challenge. Our experience on two cases and review of the literature.

Angiolipomas are rare benign mesenchymal tumours, most commonly found in the subcutaneous tissue of the extremities. These neoplasms are rarely located in the central nervous system (CNS), with spinal localization being the most common in this group. Intracranial location is extremely infrequent, and only ten cases have been described in the sellar region. We report on two more patients with skull-base (intracranial) angiolipomas, the former presented with a long history of headache and the latter complained diplopia. Both patients were postoperatively verified as angiolipoma. Neuroimaging studies and peroperative features are presented and the role of microsurgery is discussed. On the basis of these tumours' characteristics, the management strategy of choice usually does not consist on surgical total removal, often a partial excision could be satisfying to improve the patient symptomatology. Nowadays, Gamma Knife surgery is standing out as an effective, additional and/or alternative, treatment modality.

A model for rural trauma care.

BACKGROUND: In the United States and many other countries, there has been limited attempt to develop a trauma system that addresses the unique trauma situations that occur in rural areas. Rather the planners have attempted to simply extend the urban based trauma system into rural communities. This extension does not address the needs of the majority of patients who are injured in rural communities. METHODS: A review of the types of patients seen in the rural communities, the volume of these patients and the destination protocols used in the rural communities as taught by the ACS/ATLS and the implications of the CDC Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage were reviewed, assessed and compared to the needs in the rural areas for a rural trauma system. In addition, a quality assessment tool was used from a major trauma centre whereby the frequency of patients transported to the centre that were inappropriate for the trauma centre was indicated by the volume that were discharged in 6 h. RESULTS: Most of the patients injured in the rural communities can be treated in the critical access and rural hospital (> 90 per cent) and can be provided with good care without the need for emergency medical service (EMS) transportation long distances to the trauma centre, inappropriate use of air EMS vehicles thus circumventing families having to travel long distances to see patients, incurring expense and inconvenience, and avoiding loss of revenue to the local hospitals and the overload of urban trauma centres. Rather triage criteria can be taught as per the EMS systems, training given to rural hospital personnel, hospital administrators instructed as to the benefit of such a system, citizens educated as to the advantage of keeping their loved ones closer to home and trauma system registries used to enhance the correct use of the trauma system. CONCLUSION: Only 5-10 per cent of trauma injuries require the resources of a trauma centre. Proper triage and medical provider education can be used for the benefit of the patient, the EMS system, the rural and urban hospital, and proper quality assurance to assure that the 'right patient is treated at the right hospital at the right time', for the benefit of the patient.

Peripheral median nerve stimulation for the treatment of iatrogenic complex regional pain syndrome (CRPS) type II after carpal tunnel surgery.

We report on the use and follow-up of direct peripheral nerve stimulation of the median nerve for the treatment of iatrogenic complex regional pain syndrome (CRPS). A 56-year-old woman presented with CRPS type II in the right forearm and hand, which had started after multiple carpal tunnel surgeries and had lasted for 2 years. The visual analogue scale (VAS) score was 8-10 out of 10. After a successful 15-day trial of median nerve peripheral nerve stimulation via a quadripolar lead in the right carpal tunnel space, an implantable pulse generator was inserted in the right infraclavicular space. The VAS score decreased to 1-2 out of 10 and the patient regained the ability to sleep. After 36 months of follow-up, the patient was still experiencing good pain relief without other treatment. We conclude that peripheral nerve stimulation is easy to use in pain management and could offer a valid treatment option for iatrogenic CRPS type II.

Spontaneous intraparenchymal tension pneumocephalus triggered by compulsive forceful nose blowing.

The case is described of a 50-year-old man, treated for 10 years in an outpatient psychiatric clinic for an obsessive compulsive disorder, who presented with acute loss of consciousness after forceful nose blowing. A CT scan revealed an intraparenchymal air collection with tension signs in the left frontal lobe and a bone defect in the roof of the ethmoid sinus. After emergency left frontal craniotomy and dura opening, the gaseous collection was evacuated by a ventricular catheter inserted into the brain and the bone defect was repaired with pericranium flap and muscle. The postoperative course was uneventful with neurocognitive improvement and regained motility. Spontaneous tension pneumocephalus is a rare life-threatening condition which is often caused by a bone defect near the tegmen tympani. This case illustrates both an unusual cause and a unique surgical treatment for spontaneous tension intraparenchymal pneumocephalus. It can be a dangerous entity with potential for early mortality and long-term morbidity if not promptly decompressed. The pathogenesis, diagnosis and surgical strategies for spontaneous tension pneumocephalus are briefly discussed.

A rare symptomatic presentation of ecchordosis physaliphora: neuroradiological and surgical management.

We report a case of ecchordosis physaliphora, an uncommon benign lesion originating from embryonic notochordal remnants, intradurally located in the prepontine cistern, that unusually presented associated with symptoms. MRI detected and precisely located the small mass. At surgery, a cystic gelatinous nodule was found ventral to the pons, contiguous with the dorsal wall of the clivus via a small pedicle. Histological examination diagnosed the lesion as an ecchordosis physaliphora. Here we focus on the analysis of the neuroradiological aspects that play a crucial role from both a diagnostic and a therapeutic standpoint.

Excimer Laser Assisted Non-occlusive Anastomosis (ELANA). Our experience with a training model in vivo.

AIM: In this study the ELANA Technique has been reproduced in our experimental laboratory in order to verify its feasibility and reproducibility, the percentage of patent anastomosis in acute at different steps along the learning curve of the surgical team, specific problems related to the surgical technique. METHODS: In 20 rabbits New Zealand 4kg body weight the training model in vivo proposed by Tulleken and coworkers has been reproduced, realizing 40 ELANA anastomosis. The model consists in the realization of two different end-to-side anastomosis on the abdominal aorta of each experimental animal, assisted by a special designed suction/excimer laser catheter, then connected by an end-to-end suture. After a few hours the animals are sacrificed and the by-pass site withdrawn and examined in order to verify the percentage of patency in acute. RESULTS: In the first 5 animals (group A), the anastomosis were realized using a jugular vein graft and the procedure results successful in only 3 cases out of ten (30%). For the following experiments - groups B, C and D where an aorta artery graft was used, the percentage of arterial flap retrieval was respectively 50%, 60% and 80%. CONCLUSIONS: ELANA is a feasible fascinating microsurgical technique for the realization of high flow, non-occlusive anastomosis. The rate of success results progressively higher along the learning curve of the surgical team. In our opinion, before the application of the ELANA technique on humans, a period of propaedeutic training in vivo on laboratory animals is essential for the dedicated team.

Effects of nimesulide on constitutive and inducible prostanoid biosynthesis in human beings.

BACKGROUND: The aim of this study was to test the hypothesis that nimesulide, a nonsteroidal antiinflammatory drug, or its principal metabolite 4-hydroxynimesulide, is a selective inhibitor of prostaglandin H synthase-2 in human beings. METHODS: Heparinized whole blood samples obtained from healthy subjects were incubated with lipopolysaccharide (10 micrograms/ml) for 24 hours at 37 degrees C and prostaglandin E2 was measured in plasma as an index of monocyte prostaglandin H synthase-2 activity. The production of thromboxane B2 in whole blood allowed to clot at 37 degrees C for 60 minutes was assessed as an index of platelet prostaglandin H synthase-1 activity. We also measured the urinary excretion of 11-dehydrothromboxane B2, prostaglandin E2, 6-ketoprostaglandin F1 alpha, and thromboxane B2 as in vivo indexes of cyclooxygenase activity. All prostanoids were measured by previously validated radioimmunoassay techniques. RESULTS: In the whole blood assays in vitro, nimesulide was twentyfold more potent than 4-hydroxynimesulide toward the two isozymes and both compounds displayed a twentyfold preference for prostaglandin H synthase-2 versus prostaglandin H synthase-1. The administration of a single oral dose of 100 mg nimesulide to six healthy subjects significantly (p < 0.01) reduced monocyte prostaglandin H synthase-2 and prostaglandin H synthase-1 activity ex vivo by more than 90% and 50%, respectively, up to 6 hours. At 24 hours, prostaglandin H synthase-2 but not prostaglandin H synthase-1 activity was significantly reduced by 49% (p < 0.05). Nimesulide significantly (p < 0.05) reduced the urinary excretion of 11-dehydrothromboxane B2 and 6-ketoprostaglandin F1 alpha by approximately 30% and 25%, respectively, while not affecting that of prostaglandin E2 and thromboxane B2. CONCLUSIONS: Nimesulide is a potent inhibitor of human monocyte prostaglandin H synthase-2. However, despite a twentyfold selectivity ratio, therapeutic plasma levels of nimesulide are sufficiently high to cause detectable inhibition of platelet prostaglandin H synthase-1.

Effects of the novel anti-inflammatory compounds, N-[2-(cyclohexyloxy)-4-nitrophenyl] methanesulphonamide (NS-398) and 5-methanesulphonamido-6-(2,4-difluorothio-phenyl)-1-inda none (L-745,337), on the cyclo-oxygenase activity of human blood prostaglandin endoperoxide synthases.

1. We have evaluated the selectivity of ketoprofen and two novel nonsteroidal anti-inflammatory drugs, N-[2-(cyclohexyloxy)-4-nitrophenyl]methanesulphonamide (NS-398) and 5-methanesulphonamido-6-(2,4-difluorothiophenyl)-1-indano ne (L-745,337), in inhibiting the cyclo-oxygenase activity of prostaglandin endoperoxide synthase-2 (PGHS-2) vs PGHS-1 in human blood monocytes and platelets, respectively. 2. Heparinized whole blood samples were drawn from healthy volunteers pretreated with aspirin, 300 mg 48 h before sampling, to suppress the activity of platelet PGHS-1 and incubated at 37 degrees C for 24 h with increasing concentrations of the test compounds in the presence of lipopolysaccharide (LPS, 10 micrograms ml-1). Immunoreactive PGE2 levels were measured in plasma by a specific radioimmunoassay as an index of the cyclo-oxygenase activity of LPS-induced monocyte PGHS-2. 3. The effects of the same inhibitors on platelet PGHS-1 activity were assessed by allowing whole blood samples, drawn from the same subjects in aspirin-free periods, to clot at 37 degrees C for 1 h in the presence of the compounds and measuring immunoreactive thromboxane B2 (TXB2) levels in serum by a specific radioimmunoassay. 4. Under these experimental conditions, ketoprofen enantioselectively inhibited the cyclo-oxygenase activity of both PGHS-1 and PGHS-2 with equal potency (IC50 ratio: approx. 0.5 for both enantiomers), while L-745,337 and NS-398 achieved selective inhibition of monocyte PGHS-2 (IC50 ratio: > 150). L-745,337 and NS-398 did not affect LPS-induced monocyte PGHS-2 biosynthesis to any detectable extent. 5. We conclude that L-745,337 and NS-398 are selective inhibitors of the cyclo-oxygenase activity of human monocyte PGHS-2. These compounds may provide adequate tools to test the contribution of this novel pathway of arachidonate metabolism to human inflammatory disease.

Induction of prostaglandin endoperoxide synthase-2 in human monocytes associated with cyclo-oxygenase-dependent F2-isoprostane formation.

1. The isoprostane 8-epi-prostaglandin (PG)F2 alpha is produced by free radical-catalyzed peroxidation of arachidonic acid. It may also be formed as a minor product of the cyclo-oxygenase activity of platelet PGH synthase (PGHS)-1. We investigated 8-epi-PGF2 alpha production associated with induction of the human monocyte PGHS-2 and its pharmacological modulation. 2. Heparinized whole blood samples were drawn from healthy volunteers, 48 h following oral dosing with aspirin 300 mg to suppress platelet cyclo-oxygenase activity. One ml aliquots were incubated with lipopolysaccharide (LPS: 0.1-50 micrograms ml-1) for 0-24 h at 37 degrees C. PGE2 and 8-epi-PGF2 alpha were measured in separated plasma by radioimmunoassay and enzyme immunoassay techniques. 3. Levels of both eicosanoids were undetectable (i.e. < 60 pg ml-1) at time 0. LPS induced the formation of PGE2 and 8-epi-PGF2 alpha in a time- and concentration-dependent fashion, coincident with the induction of PGHS-2 detected by Western blot analysis of monocyte lysates. After 24 h at 10 micrograms ml-1 LPS, immunoreactive PGE2 and 8-epi-PGF2 alpha averaged 10,480 +/- 4,643 and 295 +/- 140 pg ml-1 (mean +/- s.d., n = 6), respectively. 4. Dexamethasone and 5-methanesulphonamido-6-(2,4-difluorothiophenyl)-1-indano ne (L-745,337), a selective inhibitor of the cyclo-oxygenase activity of PGHS-2, reduced PGE2 and 8-epi-PGF2 alpha production in response to LPS. 5. Isolated monocytes produced PGE2 and 8-epi-PGE2 alpha in response to LPS (10 micrograms ml-1) in a time-dependent fashion. Monocyte PGE2 and 8-epi-PGF2 alpha production was largely prevented by dexamethasone (2 microM) and cycloheximide (10 micrograms ml-1) in association with suppression of PGHS-2 but not of PGHS-1 expression. 6. We conclude that the induction of PGHS-2 in human monocytes is associated with cyclo-oxygenase-dependent generation of the vasoconstrictor and platelet-agonist 8-epi-PGF2 alpha.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy.

OBJECTIVE: Tracheostomy is one of the most commonly performed surgical procedures in the critical care setting. The early use of tracheostomy as a method of primary airway management has been proposed as a means to decrease pulmonary morbidity and to shorten the number of ventilator, intensive care unit, and hospital days. We set out to (1) determine whether hypercarbia occurs during tracheostomy of the critically ill patient and (2) determine the extent to which the partial pressure of carbon dioxide in arterial blood (PaCO2) rises during percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. DESIGN: Prospective, open clinical trial. SETTING: Surgical intensive care unit and operating room in teaching hospitals. PATIENTS: During mechanical ventilation, patients underwent either percutaneous endoscopic (PET), percutaneous Doppler (PDT), or standard surgical tracheostomy (ST), based on surgeon preference. Arterial blood gas readings were obtained approximately every 4 min throughout each procedure. MEASUREMENTS AND RESULTS: All tracheostomies were successfully performed. No serious complications (including hypoxia) occurred during the study. Significant (p < 0.05 vs PDT and ST) hypercarbia (maximum delta PaCO2 24 +/- 3 mmHg) and acidosis (maximum delta pH -0.16 +/- 0.02) developed during PET. The changes in PaCO2 and pH during PDT (maximum delta PaCO2 8 +/- 2 mmHg; maximum delta pH -0.07 +/- 0.02) and ST (maximum delta PaCO2 3 +/- 1 mmHg; maximum delta pH -0.04 +/- 0.01) were markedly less pronounced. CONCLUSIONS: Continuous bronchoscopy during percutaneous tracheostomy contributes significantly to early hypoventilation, hypercarbia, and respiratory acidosis during the procedure. Percutaneous tracheostomy, when performed using the Doppler ultrasound method to position the endotracheal tube, significantly reduces CO2 retention when compared to PET. Because of a possible rise in intracranial pressure, the potential for hypercarbia should be considered when choosing the method of tracheostomy in the critically ill and/or head-injured patient, where hypercarbia may be detrimental. If PET is to be performed, steps to minimize occult hypercarbia, such as using the smallest bronchoscope available, minimizing suctioning during bronchoscopy, and minimizing the length of time the bronchoscope is in the endotracheal tube, should be undertaken.

The role of nephrectomy in the acutely injured.

HYPOTHESIS: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. DESIGN: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. PATIENTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. METHODS: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. RESULTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. CONCLUSIONS: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.

Effects of flurbiprofen and flurbinitroxybutylester on prostaglandin endoperoxide synthases.

The aim of our study was to evaluate the selectivity of flurbiprofen and flurbinitroxybutylester for inhibition of the cyclooxygenase activity of prostaglandin endoperoxide synthase-2 vs. prostaglandin endoperoxide synthase-1 in human blood monocytes and platelets, respectively. In whole blood, flurbiprofen was approximately 10-fold more potent that flurbinitroxybutylester to inhibit the cyclooxygenase activity of platelet prostaglandin endoperoxide synthase-1 (IC50 microM: 0.90 +/- 0.27 vs. 10.70 +/- 5, mean +/- S.D., P < 0.05). In contrast, the 2 compounds were equipotent to inhibit prostaglandin endoperoxide synthase-2 cyclooxygenase activity in whole blood (IC50 microM: 0.90 +/- 0.25 vs. 0.80 +/- 0.35) or isolated monocytes (IC50 microM: 0.03 +/- 0.02). Neither flurbiprofen nor flubinitroxybutylester (0.28-112 microM) affected prostaglandin endoperoxide synthase isozyme expression by lypopolysaccharide-stimulated monocytes. In whole blood, flurbinitroxybutylester was slowly converted to flubiprofen and this in turn could influence the extent of inhibition of the cyclooxygenase activity of prostaglandin endoperoxide synthase-1. In conclusion, the addition of a nitroxybutyl moiety to flurbiprofen seems to reduce its capacity to inhibit the cyclooxygenase activity of prostaglandin endoperoxide synthase-1. Whether this effect will result in a reduced risk of gastrointestinal toxicity remains to be studied in man.

Strategies to improve compliance with evidence-based clinical management guidelines.

BACKGROUND: Clinical management guidelines (CMGs) have been developed to standardize physician practices and ensure safe and cost-effective patient care. In June 1996, evidence-based CMGs were initiated at our urban Level I trauma center. This study compares physician compliance with two such CMGs before (PRE) and after (POST) the institution of continuous surveillance by a clinical resource manager. STUDY DESIGN: For 2 months PRE resource manager surveillance hospital records were reviewed retrospectively for compliance with two CMGs. POST data were collected prospectively for 2 months by the resource manager, who alerted practitioners to deviance from CMGs to justify or document therapy alternatives. The CMGs studied addressed deep venous thrombosis and stress ulcer prophylaxis. "Under" or "over" therapy described that which fell short of or exceeded guidelines. Data were analyzed by chi-square; p < 0.05 defined statistical significance. RESULTS: Compliance with the CMGs was 48% PRE and 74% POST (p=0.001). All noncompliant instances POST (and none PRE) were altered or justified. Deep venous thrombosis and ulcer "over" therapy was significantly higher PRE (19% versus 2%, p=0.003; 49% versus 19%, p=0.001), resulting in $22,760.35 in costs. There was no difference in pulmonary embolism or gastrointestinal bleed rate (1%) PRE to POST. CONCLUSIONS: The use of a clinical resource manager empowered to monitor and coordinate physician behavior improves compliance with CMGs. Further study is warranted to validate resultant outcomes benefit, specifically cost-effectiveness and duration of the need for such a program.

Early partial reperfusion in a new rat model of focal cerebral ischaemia.

The influence of early partial reperfusion in a new rat model of focal cerebral ischaemia was investigated. Two groups, each of 30 adult male rats, were subjected to permanent occlusion of the right middle cerebral artery. The former, (group A) had an additional permanent occlusion of both common carotid arteries; the latter (group B) had a temporary carotid occlusion lasting for two hours. Mortality rate, evaluated within three days, was 70% in group A and 20% in group B. The mean size of cerebral infarcts was 63% in group A whereas it was 21% in group B. These data suggest that, in this animal model, early partial reperfusion is effective in reducing the mortality rate, and the size of the cerebral infarcts. Furthermore, this experimental model appears suitable for studies elucidating the role of reperfusion and/or other efforts in focal cerebral ischaemia.

The damage control sequence and underlying logic.

With the growing understanding of the pathophysiology of exsanguination has come the evolution of extraordinary surgical techniques designed to improve survival. As the success of damage control has grown, so has its acceptance in the traditional surgical community. Our challenge now is to scientifically define patient selection, refine intraoperative techniques, and acquire a greater clinical and basic science understanding of the physiology of exsanguination and reperfusion injury in resuscitation. In these efforts, overall survival should continue to increase and morbidity should continue to decrease.

Out-of-hospital rapid-sequence induction for intubation of the pediatric patient.

OBJECTIVE: To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population. METHODS: The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted. RESULTS: Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5-17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI. CONCLUSIONS: 1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.

Recidivism in equestrian trauma.

A 3-year chart survey and questionnaire was conducted of equestrian-injured patients at a regional trauma center to determine patterns and consequences of injury and rate of recidivism. Ninety-two patients (95 encounters) were treated; most were young (mean age, 27 +/- 11 years) women (84%) riders sustaining falls (80%). Most injuries were orthopedic (47%); 19 per cent of patients required hospital admission. There was one death. Helmet use was documented in only 34 per cent. Eighty-one per cent of patients responded to a follow-up telephone survey; 36 per cent recounted additional accidents (mean, 1.4 +/- 0.5). Mean time lost from work was 3 weeks, with 19 per cent reporting chronic disability. Mean annual hospital charges for the cohort were $88,925.00. Recidivism is common in equestrian trauma. Hospital charges are significant. Lost time from work is considerable, with one in five patients reporting long-term disability. Given the cost and disability incurred with equestrian trauma, efforts at injury prevention appear warranted.

Preoperative radiographic staging for ureteral injuries is not warranted in patients undergoing celiotomy for trauma.

Preoperative radiographic staging of the urinary tract has been shown to be inaccurate with regard to the ureter. The purpose of this study was to assess the need for radiographic staging of the injured patient for the diagnosis of ureteral injury before operative exploration. We conducted a retrospective review of all patients who sustained injury of the ureter as the result of external trauma over an 8 Y2-year period at an urban and suburban Level I trauma center. All patients were injured through penetrating mechanisms and underwent laparotomy. Only three patients had preoperative radiographic staging of the urinary tract. No ureteral injuries were missed. We conclude that surgical exploration of the ureter is sufficiently accurate to obviate the need for preoperative radiographic staging of the ureters in patients who have sustained penetrating injury and warrant laparotomy.

Combined blunt cardiac and pericardial rupture: review of the literature and report of a new diagnostic algorithm.

The spectrum of blunt cardiac injury varies from the asymptomatic cardiac concussion to the immediately fatal cardiac rupture. Although the majority of victims sustaining blunt cardiac rupture die before receiving medical attention, some survive to evaluation. The diagnosis of cardiac rupture, if established, typically results from the signs and symptoms of pericardial tamponade. However, some patients may have remarkably few signs and symptoms suggestive of cardiac injury and represent a significant diagnostic challenge. We provide two cases of cardiac rupture in which the diagnosis was delayed by the presence of an associated pericardial tear with decompression into the mediastinum and pleural space. In neither of the cases did existing institutional algorithms for blunt cardiac injury assist in establishing the diagnosis before the acute demise of the patient. The presence of a coexisting pericardial injury in these patients with blunt cardiac rupture obscured the diagnosis, leading to the deaths of these patients. A discussion of these two cases and review of the literature is provided with recommendations for diagnostic algorithms in patients sustaining blunt thoracic trauma with possible cardiac and pericardial injury.