Bilateral blunt carotid artery injury: a case report and review of the literature.

A 22-year-old man sustained a strangulation-type injury to the neck, with bilateral blunt carotid artery injuries detected on computed tomography (CT) angiography. His Glasgow Coma Score was 15/15, and he was managed conservatively with therapeutic low-molecular-weight heparin and antiplatelet therapy. A repeat CT angiogram 6 weeks later showed complete resolution of an intimal flap, and he demonstrated no neurological deterioration. There are no definitive management guidelines regarding this type of injury, and our report emphasises the role of conservative anticoagulation therapy in the management of this rare condition.

Base deficit as an early marker of coagulopathy in trauma.

BACKGROUND: The acute coagulopathy of trauma is associated with hypoperfusion, metabolic acidosis and an increased mortality rate. Biochemical markers of hypoperfusion, namely base deficit (BD) and lactate, are commonly used to assess the degree of hypoperfusion. Early identification of hypoperfusion and acidosis using BD and lactate may help predict the development of coagulopathy in trauma patients and direct therapy. OBJECTIVES: To identify whether a correlation exists between BD, lactate, injury severity, early-onset coagulopathy and mortality. METHODS: A retrospective chart analysis was undertaken of patients transferred directly from scene to the level I trauma unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa, from 2007 to 2008. Patients with evidence of hypoperfusion were selected. Hypoperfusion was defined as a base deficit >-2 and coagulopathy as an International Normalized Ratio (INR) of >1.2. BD, lactate, chloride, temperature, Injury Severity Score (ISS), INR and mortality were recorded in this cohort. Student's t-test and Fisher's exact test were used for continuous and categorical variables, respectively. Correlation curves were used to determine the degree of association between the variables BD, lactate and ISS with respect to the INR. A p-value of <0.05 was considered statistically significant. RESULTS: Of the 28 patients, males (n=18) accounted for 64.3% of admissions. The mean age was 31 years (range 1 - 75 years, median 30 years). The mechanism of injury was penetrating trauma in 5 cases (17.9%) and blunt trauma in 23 (82.1%). The median ISS was 24 (range 4 - 59). In 16 patients (57.1%) the INR was within normal limits, but in 12 (42.9%) it was over 1.2. There was a significant correlation between BD, ISS and INR (r=0.393; p=0.019 and r=0.565, respectively; p<0.001). Lactate showed a weak and non-significant association with the INR (r=0.232; p=0.18). There were a total of 12 deaths (42.8%) in this cohort of patients with biochemical evidence of hypoperfusion. There was a significant increase in mortality in patients with evidence of hypoperfusion and an elevated INR (75.0% v. 18.7%; p=0.006). CONCLUSION: BD but not lactate correlates with the development of the coagulopathy of trauma. The ISS showed a significant correlation with coagulation disturbances, and the combination of hypoperfusion and coagulopathy was associated with a significant increase in mortality.

Predictors of treatment refusal in patients with colorectal cancer: A systematic review.

This systematic review was conducted to investigate predictors of treatment refusal in colorectal cancer (CRC) patients. An understanding of these predictors would inform statistical models for the identification of high-risk patients who might benefit from interventions that seek to improve treatment compliance. We performed a search of PubMed and Scopus to identify potentially relevant studies on predictors of treatment refusal in CRC patients that were published between January 1, 2000 and December 31, 2021. We screened manuscripts using predefined eligibility criteria. Information on study design, study location, patient characteristics, treatments, rates and predictors of treatment refusal, and the impact of treatment refusal on mortality or survival were collected from eligible studies. Study quality was assessed using the Newcastle-Ottawa score. The overall findings of the review process were summarized using descriptive statistics and a narrative synthesis. A total of 13 studies were included in this review. Ten studies reported on refusal of CRC surgery, refusal rate: 0.25%-3.26%; three studies reported on chemotherapy refusal (one of which reported on both surgery and chemotherapy refusal), refusal rate: 7.8%-41.5%; and one study reported on refusal of any cancer treatment, refusal rate: 8.7%. The bulk of the published literature confirmed the harmful association between treatment refusal and poor survival outcomes in CRC patients. Frequently cited predictors of treatment refusal included patient demographic characteristics (age, race, gender), clinical characteristics (disease stage, comorbidity), and factors that impact access to cancer care services (healthcare insurance, facility level). Potentially high rates of treatment refusal pose a challenge to CRC control. This review has identified several factors which must be considered when attempting to reduce treatment refusal in CRC patients. Furthermore, these factors should be tested as components of predictive risk models for this important outcome.

Surgical management of psoas abscess in the Human Immunodeficiency Virus era.

OBJECTIVES: Thai aims of this study were to provide an epidemiological and microbiological analysis of psoas abscess in the human immunodeficiency virus (HIV)-infected population, and to describe the optimal investigative and management approach of this condition. METHODS: A retrospective chart analysis of 20 patients with a diagnosis of psoas abscess admitted to a regional academic hospital from January 2012 to December 2014 was performed. RESULTS: Twenty patients with psoas abscess were identified, of which 14 were HIV positive (70%) and five HIV negative (25%). One patient remained untested (5%). The mean CD4 count was 402 cells/mL (range 150-796 cells/mL, median 367 cells/mL). Acid fast bacilli were positive in psoas abscess aspirates in 13 cases (65%). Staphylococcus aureus and Escherichia coli were identified in 15% of cases. The radioisotope bone scan showed increased vertebral uptake in 10 patients (62.5%), with the lumbar spine (L1-L4) being most commonly involved (31%). There was a statistically significant increase in radioisotope uptake in the lumbar vertebrae in tuberculous psoas abscess than in pyogenic psoas abscess (p=0.003). Ultrasound-guided percutaneous drainage was used in 16 patients (80%) with a success rate of 87.5%; only two cases required repeat drainage (12.5%). Open drainage was used in four patients (30%) with a 100% success rate. There were no mortalities at 30-day follow-up. CONCLUSION: Tuberculous psoas abscess from underlying vertebral osteomyelitis is more common than pyogenic psoas abscess. Ultrasound has high diagnostic accuracy and guides percutaneous drainage with excellent success rates. Ultrasound-guided percutaneous drainage should be regarded as the first-line therapeutic modality.

Appendicitis in the HIV Era: a South African perspective.

The relationship between HIV infection and the clinical spectrum of appendicitis has not been fully elucidated in the South African context. The aim of this study is to compare the surgical management, histopathology, and outcomes between HIV-positive and HIV-negative patients undergoing surgery for appendicitis. A retrospective chart analysis was performed of 50 patients who underwent surgery for appendicitis at King Edward VIII Hospital, Durban, South Africa between January 2012 and December 2012. Patients were stratified by HIV serostatus into HIV-positive and HIV-negative groups. Fifty patients underwent surgery for appendicitis during the study period. Of the 50 patients, 14 were HIV-positive (28 %) and 36 were HIV-negative (72 %). Perforated appendicitis was more frequent in the HIV-positive group (50 vs. 25 %, p > 0.05). There was a significantly higher laparotomy rate in HIV-positive patients (71 vs. 33 %, p < 0.05). Granulomatous inflammation of the appendix was only noted in HIV-positive patients (n = 3). There was no significant difference in the complication rate between the two groups (p > 0.05) and no difference in the mean length of hospital stay (7.8 ± 4.89 vs. 5.8 ± 3.94 days, p > 0.05). In this retrospective study, perforated appendicitis was seen to be more common in HIV-positive patients resulting in a higher laparotomy rate in this group. Granulomatous inflammation was only found in HIV-positive patients. There was no difference seen in the complication rate, length of hospital stay, and mortality between HIV-positive and HIV-negative patients.

Fibroadenoma of the breast in a South African population -a pilot study of the diagnostic accuracy of fine needle aspirate cytology and breast ultrasonography.

BACKGROUND: The triple assessment of clinical breast exam (CBE), fine needle aspirate cytology (FNAC) and breast ultrasonography (US) is used in many settings for the diagnosis of fibroadenoma (FA). The diagnostic accuracy of FNAC and US for FA in South African (SA) women with palpable breast masses (PBM) is unknown. OBJECTIVE: To report the diagnostic accuracy of FNAC/US for FA in SA women with PBM. METHODS: We conducted a retrospective pilot diagnostic study of 91 women who presented with PBM to a SA regional academic hospital. Data for CBE, US, unguided FNAC, and open biopsies was collected from study participant medical records and analyzed using diagnostic accuracy tables. RESULTS: A total of 57/91 (62.6%) study participants had uninterpretable FNAC results. No study participants had uninterpretable US results. The overall diagnostic accuracy of FNAC for FA was 36.3% (95% Confidence Interval - CI: 27.1-46.5%). The overall diagnostic accuracy of US for FA was 83.5% (95% CI: 74.6-89.8%). CONCLUSION: The yield of interpretable test results for FNAC was poor in our study. The diagnostic accuracy of US for FA appears to be superior to that of FNAC. Omission of FNAC from the triple assessment in our setting should be considered.