Trauma patients and whole-body computerized tomography imaging: Location of CT-Scan and factors affecting mortality.

OBJECTIVE: : We aimed to study the factors affecting the mortality of trauma patients who underwent whole-body computerized tomography (CT) on Emergency department (ED) time frames in a developing emergency care system. Materials and Methods: This is a retrospective analysis of adult patients who received WBCT from August to November for two consecutive years (2014 and 2015). Non-parametric statistical methods were used to compare the patients who died and survived. The Backward logistic regression model was used to define factors significantly affecting mortality. RESULTS: : During 2014, 200 patients out of 827 (24.1%) received WBCT. During 2015, 263 patients out of 951 (27.6%) received WBCT. Four hundred sixteen patients were entered into the analysis. The overall mortality was 3.4% (7% in 2014 and 1% in 2015, P = 0.002). Significant factors found in backward logistic regression model defining factors affecting mortality were ISS (p < 0.0001), Glasgow Coma Scale (GCS) (p = 0.001). CT location (outside the ED in 2014, inside the ED in 2015) showed a very strong trend for affecting mortality (p = 0.054). Patients who had WBCT in the ED had lower ISS (p < 0.0001). CT imaging in the ED decreased ED to CT time 15.5 minutes (p < 0.0001), but admission time was 75.5 minutes longer. CONCLUSIONS: ISS and GCS were the main factors predicting mortality in patients who received WBCT. Patients received more WBCT imaging and physicians showed a tendency to order WBCT for less severe patients when the CT located in the ED. CT location did not show a significant effect on mortality, but on some operational time frames.

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.

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.

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.].

Head injuries in warfarinised patients.

INTRODUCTION: The objective of this study was to study the clinical course and outcome of warfarinised patients who were hospitalised because of head trauma. METHODS: 13 patients (ten males and three females; median age 69 years) who presented to the Royal Perth Hospital, Australia and who had suffered a head injury between July 1994 and June 2000 while concurrently taking warfarin, were studied. RESULTS: Confusion was the commonest presenting symptom (four patients). Five patients presented after more than 24 hours of the injury. Eight patients were anticoagulated for thromboembolic disease and five for atrial fibrillation. The patients had a median injury severity score of 25 (range 1-43). The median international normalised ratio was 2.4 (range 1.8-10) on admission and 1.8 (range 1.0-10) on discharge. 11 of the 13 patients had computed tomography of the head. Intracerebral bleeding was the commonest injury (nine patients). The median length of hospital stay was six days (range 3-30). Five patients died (38.5%). CONCLUSION: Warfarinised patients who sustain minor head trauma should be hospitalised for close neurological observation and should have a low threshold for performing computed tomography.

Primary anterior abdominal wall actinomycosis.

Actinomycosis of the anterior abdominal wall is rare. We report a 50-year-old diabetic man who presented with a left hypochondrial mass of three weeks duration associated with fever. Abdominal computed tomography showed a 2 x 4 cm mass projecting from the internal abdominal wall associated with surrounding inflammation. The mass did not decrease after a week of intravenous antibiotics. Excision of the mass and primary closure of the abdominal wall were performed. The mass involved the deep muscles of anterior abdominal wall. The omentum was adherent to the parietal peritoneum underneath the mass. Microscopical examination of the mass was consistent with actinomycosis. The postoperative period was uneventful and the patient recovered completely. The patient received penicillin for six months.

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.

Manganese superoxide dismutase: a marker of ischemia-reperfusion injury in acute pancreatitis?

Recent evidence has suggested that ischemia-reperfusion injury is fundamental to the pathogenesis of acute pancreatitis. This study was designed to determine whether acute pancreatitis is associated with elevated serum manganese superoxide dismutase (MnSOD), a key antioxidant enzyme, considered a marker of ischemia-reperfusion injury in myocardial infarction. Thirty-four patients with acute pancreatitis had measurements of MnSOD on days 0, 2, and 5 after recruitment. The patients were recruited within 12 h of admission to hospital and had measurements of MnSOD on days 0, 2, and 5. Patients with severe acute pancreatitis had significantly elevated serum MnSOD concentrations on days 2 and 5 compared with patients with mild acute pancreatitis, but not on the day of recruitment. Elevated serum MnSOD correlated with peripheral plasma markers of lipid peroxidation (malondialdehyde) and neutrophil activation (myeloperoxidase) and was associated with decreased plasma ascorbic acid concentrations. The serial measurement of serum MnSOD may prove useful as a marker of the effectiveness of treatment designed to limit ischemia-reperfusion injury in patients with severe acute pancreatitis.

Heparin ameliorates pulmonary hypertension induced by platelet-activating factor in pigs.

The purpose of this study was to investigate the effects of heparin on the haemodynamic changes which were induced by platelet-activating factor in the pulmonary and systemic circulation in pigs. Mean arterial pressure and mean pulmonary arterial pressure were measured continuously in five anaesthetised juvenile pigs. Bolus doses of platelet-activating factor (0.2-2 microg) were given intravenously to establish a dose response curve. Heparin (300 units/kg) was given intravenously. Thirty minutes later, the same doses of platelet-activating factor were repeated to establish a second dose response curve. Platelet-activating factor caused a dose dependent pulmonary artery hypertension, associated with an initial systemic hypotension followed by systemic hypertension. Heparin effectively reduced the low dose (0.2 microg) platelet-activating factor-induced pulmonary arterial hypertension (p<0.01) but not the higher doses. It had no effect on the platelet-activating factor-induced systemic hypotension or hypertension. The pulmonary and systemic circulation responded differently to platelet-activating factor after giving heparin. While heparin ameliorated the platelet-activating factor-induced pulmonary hypertension, it did not affect the changes in the systemic circulation.

Plasma von Willebrand factor and intestinal ischaemia-reperfusion injury in rats.

The purpose of this study was to determine whether plasma von Willebrand factor concentrations are correlated with the degree of intestinal ischaemia-reperfusion injury. Forty-six anaesthetised adult Wistar rats were divided into five groups. The sham-operated group (S, n=10) had laparotomy and isolation of the superior mesenteric artery without clamping. Three ischaemia-reperfusion groups (n=10 in each) had clamping of the superior mesenteric artery for 15, 30, and 45 minutes, respectively, and reperfusion for 15 minutes. A control group (C, n=6) had direct puncture of the heart to sample blood. Mean arterial pressure was measured continuously. Blood was collected at the end of the study to measure von Willebrand factor. The small bowel injury was graded histologically. There was a significant systemic hypotension after declamping in all ischaemia-reperfusion groups, which had a high negative correlation with the histological score (R=-0.46, F=10.1, p<0.003, simple linear regression). Plasma von Willebrand factor was significantly elevated in the three ischaemia-reperfusion groups compared with the control group but not significantly different from the sham-operated group (mean von Willebrand factor concentration (SEM): 156 (29), 283 (29), 295 (25), 381 (44), and 366 (40)% in C, S, ischaemia-reperfusion 15, ischaemia-reperfusion 30, and ischaemia-reperfusion 45 groups, respectively). The concentration of von Willebrand factor was not correlated to the histological score (R=0.22, F=1.83, p<0.2) or the degree of hypotension after the removal of the clamp (R=-0.22, F=1.8, p<0.2, simple linear regression). This study shows that von Willebrand factor concentration does not correlate with the degree of intestinal ischaemia-reperfusion injury. It is unlikely that von Willebrand factor can be used as a predictor of disease severity.

Three staged approach to the surgical management of renal cell carcinoma extending into the right atrium. Case report.

Left renal cell carcinoma extending into the right atrium was treated by angioinfarction, removal of right atrial tumour using cardiopulmonary bypass and ten days later abdominal radical nephrectomy and inferior vena cava thrombectomy. Twenty four months later the patient remains well with no evidence of tumour recurrence.

Gallbladder tuberculosis (case report and review of the literature).

The incidence of abdominal tuberculosis is increasing and the familiarity with its clinical presentation shortens its diagnostic time and improves its management. Gallbladder tuberculosis has unique considerations regarding its pathology, diagnosis and surgical management. The authors report a case of gallbladder tuberculosis in a 40 year-old female who presented with a clinical picture of acute cholecystitis. Abdominal ultrasound showed a dilated gallbladder with a large gall stone located in the neck region. Several lymph nodes were seen in the hilum of the liver compressing the portal vein which were associated with smaller retroperitoneal lymph nodes. The diagnosis of gallbladder tuberculosis was reached only during surgery and was proven by histopathology. The gallbladder was adherent to the surrounding tissues and covered with multiple tuberculous nodules. The patient had a retrograde open cholecystectomy and treated with anti-tuberculous drugs. The literature on this topic is reviewed.

Iatrogenic obstructive jaundice caused by the balloon of a Foley catheter. Case report.

A rare kind of obstructive jaundice caused by compression on the common bile duct due to an inflated Foley catheter balloon placed in the duodenum after Suguira surgery for bleeding esophageal vesicles secondary to portal hypertension is presented. After deflating the balloon, the obstruction was relieved. Tc-99m HIDA studies were helpful in the diagnosis of obstruction of the common bile duct and the response following the deflation.

The first Australian workshop on bedside ultrasound in the Emergency Department.

AIMS: Bedside ultrasound is not widely practised by emergency physicians in Australasia despite its use in Europe, Asia and North America, and an extensive medical literature on the subject. A workshop was organised at Auckland Hospital, aiming to introduce emergency physicians to the basics of emergency ultrasound. This article summarises the content of the programme, the responses from the participants and the principles that emerged at this workshop. METHODS: A standardised, 16-hour, emergency ultrasound curriculum was offered to 23 participants. Lectures with syllabus material were used to cover the following topics: basic ultrasound physics, pelvis, right upper quadrant, renal, aorta, trauma and echocardiography. Each participant received eight hours of hands-on ultrasound instruction. On completion of the course participants responded anonymously to a course appraisal questionnaire. RESULTS: Twenty-one participants responded to the questionnaire (91% response rate). Delegates found the course informative and the material was considered relevant. Workshop objectives were met and the venue was appropriate. Most participants thought the practical sessions could be improved by decreasing the ratio of delegates to human models. CONCLUSIONS: The first Australasian workshop on bedside ultrasound in the Emergency Department held in Auckland (February 1998) was successful in achieving its objectives. Focused emergency ultrasound can be taught to detect free intraperitoneal or pericardial fluid in trauma patients. There is a need for appropriate quality assurance and credentialling guidelines as more Australasian emergency departments consider the application of focused ultrasound.

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.

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.

Urologic injuries in the Gulf War.

This study aims to compare the urologic injuries treated at Kuwait during the Gulf War with those recently reported by the United States urologic surgeons. Gunshot caused the majority of the injuries (58%) on our side of the battle compared with fragmentation injuries (83%) on the other side. We had statistically significant higher renal and ureteric injuries (14/35 compared with 5/30; p<0.04, Chi-square). This difference can be explained by the use of the flak jackets on the other side or the difference of the type of weapons used. Our management had a similar preservative approach. Only 4/12 of renal injuries (33%) had nephrectomy. Two ureteric injuries were missed by general surgeons which were successfully managed by the urologists. This study supports the presence of urologists within military surgical teams.