Searching for mortality predictors in trauma patients: a challenging task.

BACKGROUND: We aimed to study the value of new physiological variables compared with ISS and GCS as predictors for trauma mortality in a high-income developing country having a young population. METHODS: Data of 1008 consecutive trauma patients who were included in Al-Ain City Road Traffic Collision Registry were analyzed. Demography of patients, systolic blood pressure, heart rate, shock index, shock index age (SIA), blood pressure age index (BPAI), Glasgow Coma Scale (GCS), injury severity score (ISS), and in-hospital mortality were analyzed. Univariate analysis was used to compare those who died with those who survived. Significant factors were then entered into a backward logistic regression model to define factors predicting mortality. RESULTS: 80.3% of the patients were males. The median (range) age of patients was 26 (1-78) years. Significant factors that predicted mortality were GCS (p < 0.0001), SIA (p = 0.003), ISS (p = 0.007), and BPAI (p = 0.022). CONCLUSIONS: The physiological variables including GCS and shock index age were better predictors for trauma mortality comparted with ISS in our young population. A large global multi-centric study could possibly define an accurate global formula that uses both anatomical and physiological variables for predicting trauma mortality.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA).

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Gynaecological laparoscopy courses in the United Arab Emirates.

BACKGROUND: Laparoscopic surgery is important for gynaecological practice and became the method of choice for many gynaecological procedures having advantages over open surgery. OBJECTIVES: To report our modified teaching methods, and evaluation of the gynaecological laparoscopy courses in United Arab Emirates. METHODS: Fifty five participants attended four 3-full day comprehensive hands-on gynaecological laparoscopic skills courses. Non-expensive dry/wet models have been developed for teaching. All participants were evaluated at the end of the course through MCQs and practical laparoscopic exercises. All participants filled out a questionnaire reflecting their opinion on various aspects of the course at its completion. Ethical approval has been received by Research and Ethics Committee of Al-Ain Medical District, Al-Ain, UAE. RESULTS: Fourteen participants had no laparoscopic experience, 35 had experience at level I and six had experience at level II. There was a statistically significant difference of the MCQ mark between the three levels of experience (p = 0.05, Kruskal Wallis test) but not for the practical part, p = 0.9, Kruskal Wallis test). The courses were highly valued having an overall average rating of 3.8 out of 4. CONCLUSION: A multimodality non expensive course for teaching gynaecological laparoscopy was highly successful in United Arab Emirates. Models used may be useful for training gynaecological laparoscopy in developing countries. The long term effects of our courses on clinical practice have yet to be evaluated.

Papillary thyroid carcinoma presenting as a lateral neck cyst.

BACKGROUND: Solitary lateral cervical cystic mass is an uncommon presentation of papillary thyroid carcinoma. OBJECTIVES: To report our recent experience in the diagnosis and management of papillary thyroid carcinoma presenting as a lateral neck cyst. METHODS: Patients who had papillary thyroid carcinoma and presented as a painless lateral neck cyst at the Department of Surgery, Al-Ain Hospital, from April 2005 to June 2009 were retrospectively studied. Their clinical presentation, diagnosis and management were reviewed. RESULTS: Five patients were studied. No thyroid nodules were clinically palpable in all patients. Fine needle aspiration cytology from the cyst was positive for papillary thyroid carcinoma in three patients (60 percent). Two patients were diagnosed after excisional biopsy. Three patients had total thyroidectomy with modified radical neck dissection and postoperative radioactive iodine ablation. Two patients preferred to travel overseas for treatment. Thyroid histopathological examination has shown papillary thyroid carcinoma in all operated patients with multiple microscopic foci in two of them. This was associated with multiple bilateral cervical lymph node involvement. CONCLUSIONS: Metastatic papillary thyroid carcinoma presenting as a neck cyst is a diagnostic challenge. Excisional biopsy is indicated if fine needle aspiration cytology was inconclusive so as to rule out malignancy.

Tracheobronchial injuries following endotracheal intubation.

We report two rare cases of tracheobronchial injury (TBI) following endotracheal intubation. Both intubations were easy and performed by experienced anaesthetists. The injuries for both cases were possibly caused by the tip of an endotracheal tube. A 27-year-old woman regurgitated copiously during induction of general anaesthesia for a Caesarean section. She had a full-thickness TBI 2 cm above the carina, which was repaired through an open thoracotomy. A 68-year-old woman undergoing left mastectomy was intubated with a 7.5-mm endotracheal tube for general anaesthesia. 24 hours after extubation, the patient developed widespread subcutaneous emphysema. There was no associated respiratory distress, and the patient was treated conservatively. The fragile tracheal tissue associated with pregnancy and old age was possibly a contributing factor for injury. Both patients recovered well. Surgical and non-surgical methods can be safely used after careful consideration of the patient's clinical, radiological and endoscopic findings.

Peritoneal resorption capacity for lipopolysaccharide and interleukin-6 in acute zymosan-induced chemical peritonitis.

AIM: To evaluate peritoneal resorption capacity for lipopolysaccharide (LPS) and interleukin-6 (IL-6) in a model of chemical peritonitis. METHODS: Zymosan peritonitis was induced in anesthetized rats. LPS was injected intraperitoneally to different groups at 4 h (n = 10), 8 h (n = 9), 12 h (n = 9), and 24 h (n = 9) after peritonitis and to a control group (n = 8). Similarly, IL-6 was injected intraperitoneally to different groups at 4 h (n = 9), 8 h (n = 10), 12 h (n = 10), and 24 h (n = 10) after peritonitis, and to a control group (n = 10). Plasma levels of LPS or IL-6 were measured immediately after intraperitoneal injections of LPS or IL-6, respectively, and at 5, 15, 30, 45, and 60 min later. RESULTS: There was no change over time in plasma LPS levels in the groups receiving LPS intraperitoneally (p = 0.4). There was highly significant change over time in the IL-6 level in the studied time periods in the groups receiving IL-6 intraperitoneally (p < 0.0001). There was an increase in the plasma IL-6 level when sampled at 4 h after peritonitis. CONCLUSION: There was a reduction of resorption capacity of inflamed peritoneum for inflammatory mediators in acute chemical peritonitis.

Multiple small bowel ligation compared to conventional primary repair after abdominal gunshot wound with haemorrhagic shock.

AIMS: The aim of this study was to evaluate the effects of early rapid control of multiple bowel perforations on cardiovascular function in combined abdominal missile trauma and haemorrhagic shock compared with conventional surgery. METHODS: Eighteen anesthetised pigs were injured with a standardised abdominal missile trauma. The animals were bled to a mean arterial pressure of 50 mm Hg for 30 minutes, after which they were resuscitated and had laparotomy. They were divided into conventional surgery group (n=9) with primary resection and anastomosis of bowel -injuries and early rapid multiple bowel ligation group (n?=?9). Repeated measurement analysis of variance was used for analysis. RESULTS: There was profound hypotension, reduced cardiac output, increased vascular resistance and lactic acidaemia in both groups. Lactic acidaemia persisted longer in the early rapid multiple bowel ligation group. There were no significant differences in mean arterial pressure, cardiac output , stroke volume or systemic vascular resistance between the groups. The mean operation time was significantly shorter in the early rapid multiple bowel ligation group (13.3 (1.5) (SEM) minutes, compared with 116.4 (1.74) (SEM) minutes in the conventional surgery group, p =0.001). CONCLUSIONS: Damage control principles have shortened the operating time in our model but did not improve the cardiovascular function and caused more lactic acidaemia than conventional repair.

Pancreatic injuries in the United Arab Emirates.

PURPOSE: To study the mechanism, management and outcome of patients who had sustained pancreatic trauma. METHODOLOGY: Patients who were treated for pancreatic trauma in Al-Ain Hospital between October 2002 and August 2007 were retrospectively studied. RESULTS: All eleven patients were males having a median age of 30 years (range 24-52 years). Nine had blunt trauma while two had suffered penetrating injury. Three presented with shock. associated injuries were present in nine patients (head, chest, and extremities) while seven had other intra-abdominal injuries. Only one patient had isolated pancreatic injury. Early serum amylase was elevated in six patients. CT abdomen was diagnostic for pancreatic injury in seven patients. Two cases were missed by early CT scan (sensitivity of 78%) while the remaining two patients were taken immediately to the operating theater. All patients underwent laparotomy. Five patients were treated by drainage alone, four had distal pancreatectomy, abdominal packing was performed in one patient and in another gastrocystostomy was carried out. Pancreatic fistula occurred in three patients. Median hospital stay was 25 days (range 12-152 days). Two patients (18%) died. CONCLUSIONS: Blunt trauma is the main cause of pancreatic injury in our country. Early CT scan may miss pancreatic injury in almost a quarter of the patients. Thin sliced CT scan, with special views in a dedicated abdominal pancreatic study, is recommended. A high index of clinical suspicion, depending on the mechanism of injury, is important for diagnosis of pancreatic injury. Mortality is mainly attributable to other associated injuries so simple procedures should initially be adopted for pancreatic injury, especially in haemodynamically unstable patients.

Management of mesenteric vascular occlusion.

INTRODUCTION: The aim of this study was to evaluate our recent clinical management of mesenteric vascular occlusion (MVO) at Al-Ain Hospital, United Arab Emirates. METHODS: A retrospective study was performed including all patients who were diagnosed to have MVO from December 2001 to May 2005. The records were studied with regard to clinical features, risk factors, diagnosis, treatment, and outcome. RESULTS: Of the 14 patients studied, seven patients experienced mesenteric venous thrombosis (MVT), five patients mesenteric arterial occlusion (MAO), and two patients were found to have both MVT and MAO. The main risk factor for MAO was ischaemic heart disease with atrial fibrillation in four patients (80 percent). No predisposing factors were identified in three patients with MVT (primary MVT 43 percent). Contrast-enhanced computed tomography was performed in all patients and was diagnostic in 12 (86 percent) patients. Seven patients (50 percent) underwent surgery. One patient died on the ninth postoperative day (overall mortality rate 7 percent). Seven patients (50 percent) were successfully managed conservatively, five of them had only MVT, one had combined MVT and MAO, and one had only MAO. CONCLUSION: Early diagnosis and prompt initiation of anticoagulation therapy, with operative intervention when indicated, are essential for a favourable outcome.

Primary umbilical adenocarcinoma.

Primary umbilical tumours are extremely rare. We report primary serous adenocarcinoma arising from the coelomic mesothelium of the hernial sac. A 60-year-old woman presented with an umbilical swelling of six months duration that became painful in the last three days. Examination revealed a tender umbilical swelling diagnosed as obstructive hernia that needed surgery. When dissecting the sac during surgery, a small subcutaneous abscess was encountered. The sac contained an omentum with a hard nodule at the surface which was excised. Umbilical hernia repair was performed. Histology of the omental nodule revealed serous papillary adenocarcinoma. Chest and abdomen computed tomography, pelvic magnetic resonance imaging, gastroscopy, colonoscopy and laparotomy did not reveal the primary site of the tumour.

Liver metastasis in renal chondrosarcoma.

A 39-year-old woman who had a left radical nephrectomy for a renal chondrosarcoma presented 18 years later with a large epigastric mass and deep jaundice. The patient was very dyspnoeic and had a feeling of continuous pressure on her chest. Computed tomography arterioportography of the abdomen showed that the mass involved both lobes of the liver. Multiple non-anatomical resections of tumour masses were performed, including a mass arising from the falciform ligament, left lateral segment, and segments VII and VIII. The largest resected mass weighed 2.5kg and had a diameter of 15cm. Histopathology of the hepatic metastasis was similar to the original renal chondrosarcoma. The patient was followed up for 24 months postoperatively and had symptomatic relief. Our case demonstrates the slow-growing nature of this tumour and the usefulness of palliative surgery despite large tumour load.

Effects of prone and supine posture on cardiopulmonary function after experimental chlorine gas lung injury.

BACKGROUND: Chlorine gas may induce severe acute lung injury. Improvement of pulmonary gas exchange in patients and animals with acute lung injury nursed in the prone position was observed in recent years. The purpose of this study was to evaluate the effects of prone and supine positions on pulmonary and cardiovascular functions following experimental chlorine gas lung injury. METHODS: Twenty anesthetized and mechanically ventilated pigs were exposed to chlorine gas (400 p.p.m. in air) for 20 min in the supine position, then assigned randomly to ventilation in the supine or prone positions (n=10 in each group). Hemodynamics, gas exchange, lung mechanics and oxygen transport were evaluated for 5 h. RESULTS: All animals showed severe pulmonary dysfunction immediately after chlorine gassing with a threefold increase in pulmonary vascular resistance index, a drop in arterial oxygenation (12.3+/-1.3 kPa to 5.4+/-0.7 kPa) and a fall in lung-thorax compliance (22+/-1 ml cmH2O-1 to 8+/-2 ml cmH2O-1). Venous admixture (Qs/Qt) improved in animals in the prone position while there was no change in the supine position (prone 32+/-11% vs. supine 42+/-9% at 5 h,P<0.05). Lung-thorax compliance improved significantly with time in the prone group only (P<0.01). Oxygen delivery increased significantly in prone animals compared with animals nursed in the supine posture (P<0.001). CONCLUSION: Immediate prone positioning after chlorine gas injury not only inhibited deterioration of gas exchange but was also associated with improved pulmonary function and oxygen transport.

Instructional skills of surgical tutors.

AIM OF STUDY: This study was aimed at evaluating the pattern of instructional skills of surgical tutors in a university hospital and the effect of feedback on this pattern. METHOD: Students who followed three clinical rotations at the Department of Surgery, Mubarak Al-Kabeer Teaching Hospital, Kuwait, responded anonymously to a structured questionnaire on the instructional skills of their tutors immediately after the rotation was completed. The questionnaire included six statements related to teacher-centred instructional skills and six statements related to student-centred instructional skills. The students indicated their perception on a five-point rating scale (very poor, poor, fair, good and very good). A summary of students' opinions was made available to the teachers soon after each rotation. RESULTS: The percentage of good/very good categories was significantly higher in the teacher-centred skills compared with the student-centred skills (median (range), 87.05% (85.9-91.7) compared with 79.6% (76.6-80.6), (p = 0.004, Mann Whitney U test). This difference was significant in the first two rotations (p < 0.005) but not in the third rotation (p=0.59). CONCLUSIONS: This study shows that behaviours of teachers which dealt directly with the learner's role in learning received lower emphasis than the teacher-centred activities and that feedback may modify this behaviour.

Students' evaluation of surgical seminars in a teaching hospital.

AIM: To evaluate the surgical seminars given for medical students at Auckland University and factors affecting them, so as to define areas for improvement. METHODS: A confidential questionnaire was completed by fourth-year medical students for each surgical seminar they attended during an academic year. The seminars were repeated four times during the year. The questionnaire consisted of five statements relating to whether the seminar was stimulating, problem- oriented, patient-centred, evidence-based and interactive. The students rated each statement on a 7-point scale. RESULTS: 556 questionnaires evaluating 28 clinical teachers were collected. A generalized linear model showed that the clinical teachers (F=4.16, P = 0.0001), the attachment (F=4.39, P=0.005) and the interaction between the seniority and institute (F=6.38, P=0.019) had a significant effect on the rating of the seminars. University consultants and hospital registrars had the highest overall least-squares mean, followed by hospital consultants, while university lecturers had the lowest overall least-squares mean (5.56, 5.4, 5.18, and 4.36, respectively). Ratings for problem-oriented approach improved over the studied period, while ratings of evidence-based and patient-centred approaches remained lower. University consultants and hospital registrars had the best patient-centred approach compared with hospital consultants and university lecturers (least-squares means 5.52, 5.4, 5.01, 4.18, respectively). Hospital registrars showed the best interactive ability ratings (least-squares mean 5.51) while university lecturers had the least stimulating seminars (least-squares mean 4.46). CONCLUSIONS: Surgical seminars which were introduced to cover surgical topics had acceptable ratings in each of the teaching domains, although there is a need for improvement in the patient-centred and evidence-based approaches.

Plasma amylin concentration is related to the severity of intestinal ischemic injury in rats.

BACKGROUND: Previous work has demonstrated that intestinal ischemia increases plasma amylin concentration. This study examined the relationship between the degree of intestinal ischemia injury and plasma amylin in an experimental rat model. METHODS: Wistar rats were divided into a control group (n = 6); a sham-operated group (n = 9); and 3 intestinal ischemia-reperfusion groups (n = 8 in each), which underwent clamping of the superior mesenteric artery for either 15, 30, or 45 minutes followed by 15 minutes of reperfusion. Samples were then collected for intestinal histology and measurement of amylin, insulin, and glucose. RESULTS: There was a positive correlation between the histologic score of the intestinal injury and the measured plasma amylin concentration (R = 0.48, P =.007). The median plasma concentration of amylin was 62 pmol/L (range, 42-97 pmol/L) in the 30-minute intestinal ischemia group and 58 pmol/L (42-86 pmol/L) in the 45-minute intestinal ischemia group. Both these groups were increased compared with the sham-operated group (29 pmol/L; range, 22-57 pmol/L; P <.001 and P <.005, respectively) and the control group (28 pmol/L; range, 26-42 pmol/L; P <.001 and P <.0005, respectively). The median plasma concentration of insulin in the 30-minute intestinal ischemia group was 4230 pmol/L (range, 1360-5770 pmol/L), which was increased compared with both the control group (950 pmol/L; range, 550-1510 pmol/L; P <.005) and the sham-operated group (720 pmol/L; range, 280-4180 pmol/L; P<.005). There were no differences between any of the other groups either for glucose, insulin, or amylin. CONCLUSIONS: Plasma amylin concentration is related to the severity of intestinal ischemic injury.