Vascular damage control at the thoracic outlet.

Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.

Beta-blocker Therapy is Associated with Decreased 1-year Mortality After Emergency Laparotomy in Geriatric Patients.

BACKGROUND AND AIMS: Emergency laparotomy is associated with a great risk of mortality in the elderly. The hyperadrenergic state induced by surgical trauma may play an important role in the pathophysiology of this increased risk. Studies have shown that beta-blocker exposure may be associated with decreased morbidity and mortality in the perioperative period. We aimed to study the effect of beta-blocker on mortality in geriatric patients undergoing emergency laparotomy. MATERIAL AND METHODS: This is a retrospective study of patients who underwent emergency laparotomy between 1 January 2015 and 31 December 2016 at a single institution. The outcomes of interest were the association between post-operative complications and in-hospital and 1-year mortality in patients on beta-blocker therapy (BB(+)) and those who were not (BB(-)). The Poisson regression analysis was used to evaluate the association. RESULTS: A total of 192 patients were included of whom 62 (32.2%) had pre-operative beta-blocker therapy with continued exposure during their hospital stay. The in-hospital mortality was 17.7% in the BB(+) and 23.8% in the BB(-) cohorts (p = 0.441). One-year mortality was significantly lower in the BB(+) group compared to the BB(-) group (30.6% versus 47.7%; p = 0.038). After adjusting for confounders, the incidence of deaths during 1 year post-operatively decreased by 35% in the BB(+) group (incidence rate ratio = 0.65, p = 0.004). No significant differences in the incidence of post-operative complications between the two groups could be measured. CONCLUSION: Beta-blocker therapy may be associated with reduced 1-year mortality following emergency laparotomy in geriatric patients.

Use of propofol as an induction agent in the acutely injured patient.

PURPOSE: Etomidate is a commonly used agent for rapid sequence induction (RSI) in trauma due to its limited hemodynamic effects. Given a recent nationwide shortage of etomidate, alternative induction agents may be required. Propofol is a frequent substitute; however, concern exists regarding its potential hypotensive effects. The study attempts to determine the hemodynamic effects of propofol and etomidate following RSI in trauma bay. METHODS: A retrospective study was performed on 76 consecutive trauma patients requiring RSI at a single academic medical center. Patients were stratified by age, gender, mechanism of injury, Injury Severity Score (ISS), and Glasgow Coma Scale (GCS). Pre-induction and post-induction hemodynamic parameters were evaluated, and a multivariate regression analysis was performed. RESULTS: The mean age was 42, ISS was 13, and GCS was 9.8. The mean dose of propofol was 127 ± 5 mg and the mean dose of etomidate was 21 ± 6 mg. Patients who received propofol were younger and had a lower ISS. The etomidate group had significantly increased post-induction systolic blood pressure but no difference in mean arterial pressure or heart rate when compared to pre-induction parameters. The propofol group had no significant changes in any post-induction parameter compared to pre-induction parameter. CONCLUSION: RSI with propofol did not result in hypotension in our patient population, suggesting that a reduced dose of propofol may represent a reasonable alternative to etomidate in hemodynamically stable trauma patient. Further research is warranted to assess the safety of propofol in the acutely injured patient.

Clinical outcomes following invasive versus noninvasive preoperative stabilization of closed diaphyseal femur fractures.

BACKGROUND: The use of invasive traction (INV-T) to stabilize femur fractures prior to fixation (open reduction and internal fixation, ORIF) remains controversial. Some centers have utilized noninvasive traction (NINV-T) or splinting preoperatively. It is possible that INV-T decreases hemorrhage. However, the use of INV-T in pediatric patients and for femoral neck fractures in adults is associated with worsened outcomes. We hypothesized that there is no difference in the need for transfusion between those who receive INV-T and NINV-T. METHODS: A retrospective study was performed at two level I and one level II trauma center from January 2006 to December 2009. Patients ≥18 years with a closed diaphyseal femur fracture who underwent ORIF within 48 h of arrival were included. Patients were grouped by method of preoperative fracture stabilization. Primary endpoint was need for transfusion. A power analysis found that 94 patients were needed to detect a 25 % difference with 80 % power. RESULTS: Fifty-six (22 %) received INV-T and 199 (78 %) received NINV-T stabilization. No significant differences were found between groups in terms of age, injury severity score, or ORIF method. There was no significant difference between the two groups in the hemoglobin value on arrival, preoperative hemoglobin value, or the difference between admission and preoperative hemoglobin values. We did not find a significant difference in the need for red blood cell transfusion between the two groups. There was no difference in length of stay or discharge destination. CONCLUSION: INV-T is not associated with improved outcomes in adult patients with closed mid-shaft femoral fractures who are operated upon within 48 h of arrival.

Biofilm accumulation on endotracheal tubes following prolonged intubation.

OBJECTIVE: To demonstrate that patients who have been intubated for prolonged periods of time will have an increased likelihood of developing bacterial biofilm on their endotracheal tubes. METHODS: We collected endotracheal tubes from patients at the time of extubation, and analysed representative sections with scanning electron microscopy for morphologic evidence of biofilms. RESULTS: From September 2007 to September 2008, 32 endotracheal tubes were analysed with electron microscopy. Patients who had been intubated for 6 days or longer had a significantly higher percentage of endotracheal tubes that exhibited bacterial biofilms, compared with patients intubated for less than 6 days (88.9 versus 57.1 per cent, p = 0.0439). CONCLUSIONS: Longer duration of intubation is associated with a higher incidence of bacterial biofilm. Further research is needed to link the presence of bacterial biofilms to acquired laryngotracheal damage.

Vena cava filters: a synopsis of complications and related topics.

Deep venous thrombosis and pulmonary embolism constitute common preventable causes of morbidity and mortality. The incidence of venous thromboembolism (VTE) continues to increase. Standard anticoagulation therapy may reduce the risk of fatal PE by 75% and that of recurrent VTE by over 90%. For patients who are not candidates for anticoagulation, a vena cava filter (VCF) may be beneficial. Despite a good overall safety record, significant complications related to VCF are occasionally seen. This review discusses both procedural and non-procedural complications associated with VCF placement and use. We will also discuss VCF use in the settings of pregnancy, malignancy, and the clinical need for more than one filter.

Nissen fundoplication has a vagolytic effect on the lower esophageal sphincter.

BACKGROUND: Laparoscopic Nissen fundoplication is an increasingly utilized option for the treatment of gastroesophageal reflux disease (GERD). However, many questions remain as to the mechanism by which this operation prevents GERD in those without hiatal hernias or incompetent lower esophageal sphincters (LES). It is known that these patients experience reflux due to excess transient lower esophageal sphincter relaxations (TLESR), inappropriate and short-lived relaxation of the LES and crural diaphragm. The purpose of this study was to determine if Nissen fundoplication affects the neural pathways involved in the TLESR reflex. METHODS: Five dogs were anesthetized and intubated. Both vagal nerves and the right phrenic nerve were isolated. A continuous water perfusion manometric catheter was situated at the LES. The nerves were then electrically stimulated and the resultant pressure at the LES measured at baseline, and during and after an open Nissen fundoplication. RESULTS: The mean LES pressures before dissection, after esophago-gastric mobilization, and after fundoplication were 47 +/- 13 mmHg, 21 +/- 9 mmHg, and 14 +/- 4 mmHg, respectively. All differences were significant. There was no change noted in LES pressure with stimulation of either or both of the phrenic nerves without concomitant vagal stimulation. CONCLUSION: Nissen fundoplication may prevent GERD in those without a hiatal hernia or incompetent LES by disrupting the efferent vagal fibers to the LES. Such fibers mediate TLESR which are responsible for GERD in these patients.

Selection criteria among gastroenterologists and surgeons for laparoscopic antireflux surgery.

BACKGROUND: Symptomatic gastroesophageal reflux disease (GERD) affects a substantial proportion of the American population. The diagnosis and treatment of GERD has advanced tremendously over the past 30 years. However, there remains a lack of understanding about the differences and advantages that laparoscopic antireflux surgery offers and a lack of agreement on the ideal surgical candidate. The purpose of this study was to determine whether a significant difference exists in the practice habits and selection criteria for surgery between gastroenterologists and laparoscopic surgeons. METHODS: Surveys were sent to 1,000 randomly selected members of the American Gastroenterological Association (AGA) and to 1,000 randomly selected members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). As a result, 20% of the AGA surveys and 33% of the SAGES surveys were completed and returned. RESULTS: The AGA group considered patients whose symptoms are not well controlled, those who have complications of disease, and those who require significant lifestyle changes to control their symptoms as the best candidates for surgical evaluation. As a group, gastroenterologists remain somewhat hesitant to refer patients for laparoscopic antireflux surgery. Surgeons considered patients whose symptoms have been well controlled with medical therapy, those who have complications of disease, and those who require significant lifestyle changes to control their symptoms as ideal candidates for fundoplication. CONCLUSION: A consensus should be reached between surgeons and gastroenterologists in establishing criteria for surgical intervention to manage GERD.

HIV-positive patients with anal carcinoma have poorer treatment tolerance and outcome than HIV-negative patients.

PURPOSE: Anal carcinoma is being found in HIV-positive patients with increasing frequency. Most patients are treated with combined chemotherapy and radiation. It was our impression that HIV-positive patients do not fare as well as HIV-negative patients in terms of both response to and tolerance of therapy. METHODS: To test this hypothesis, we reviewed our experience with anal carcinoma and compared HIV-positive to HIV-negative patients by age, gender, sexual orientation, stage at diagnosis, treatment rendered, response to treatment, tolerance, and survival. From 1985 to 1998, 98 patients with anal neoplasms were treated. Seventy-three patients had invasive squamous-cell carcinoma (including cloacogenic carcinoma), and this cohort was analyzed. Thirteen patients were HIV positive and 60 were HIV negative. RESULTS: The HIV-positive and HIV-negative groups differed significantly by age (42 vs. 62 years, P < 0.001), male gender (92 vs. 42 percent, P < 0.001), and homosexuality (46 vs. 15 percent, P < 0.05). There were no differences by stage at diagnosis or radiation dose received. Acute treatment major toxicity differed significantly (HIV positive 80 percent vs. HIV negative 30 percent; P < 0.005). Only 62 percent of HIV-positive patients were rendered disease free after initial therapy vs. 85 percent of HIV-negative patients (P = 0.11). Median time to cancer-related death was 1.4 vs. 5.3 years (P < 0.05). A survival model did not show age, gender, stage, or treatment to be independent predictors. CONCLUSION: We found that HIV-positive patients with anal carcinoma seem to be a different population from HIV-negative patients by age, gender, and sexual orientation. They have a poorer tolerance for combined therapy and a shorter time to cancer-related death. A strong trend to poorer initial response rate was also seen. These results suggest that the treatment of HIV-positive patients with anal carcinoma needs to be reassessed.

Late immunoneutralization of procalcitonin arrests the progression of lethal porcine sepsis.

BACKGROUND: Procalcitonin (ProCT) is becoming increasingly recognized as a mediator as well as a marker of sepsis. Serum ProCT concentrations rise soon after induction of sepsis and remain elevated over a prolonged period of time. In contrast, many pro-inflammatory cytokines, e.g., tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta), rise and decline early in the course of sepsis. Researchers have improved survival in animal models of sepsis by prophylactically blocking IL-1beta and TNF-alpha with immunotherapy, but therapeutic treatment has been less successful in clinical trials. We hypothesized that the sustained elevation of ProCT in the serum would allow for effective therapeutic immunoneutralization of this peptide late in the course of sepsis. METHODS: Lethal polymicrobial sepsis was induced in 10 castrated, male Yorkshire pigs by intraabdominal spillage of cecal contents (1 gm/kg) and intraabdominal instillation of 2 x 10(11) cfu of a toxigenic strain of E. coli (O18:K1:H7). The treated group (n = 5) received an intravenous infusion of purified rabbit antiserum to the aminoterminus of porcine ProCT. The control group (n = 5) received nonreactive, purified rabbit IgG. The purified antiserum was infused to all animals 3 h after the induction of sepsis, at which time very severe physiologic dysfunction was manifest, and many of the animals appeared to be preterminal. Physiologic and metabolic parameters were measured until death or for 15 h after induction of sepsis, at which time all surviving animals were euthanized. RESULTS: Therapeutic immunoneutralization of serum ProCT improved most measured physiologic and metabolic parameters in septic pigs. Specifically, there was a significant increase in mean arterial pressure, urine output and cardiac index in all animals treated with ProCT antibody. Serum creatinine was significantly lower in treated animals. Although acidosis was not as severe in treated animals, as indicated by higher pH values and lower lactate concentrations, these results did not achieve statistical significance. Significantly, 11 h after the induction of sepsis there was 100% mortality in the control group while only one animal in the treated group expired. CONCLUSION: The prolonged elevation of ProCT concentrations in sepsis allows neutralization of this peptide to be effective during the course of this disorder. These findings suggest that immunoneutralization of ProCT may be a useful treatment in clinical situations where sepsis is already fully established.

A randomized, cross-over trial of once-daily versus twice-daily parathyroid hormone 1-34 in treatment of hypoparathyroidism.

Once-daily sc injection of PTH 1-34 can normalize mean serum and urine calcium levels in patients with hypoparathyroidism; however, once-daily PTH has diminishing effects on serum calcium after 12 h, such that serum calcium levels fall below the normal range in some patients. Once-daily PTH also causes a marked increase in bone turnover, with persistent increases in markers of bone formation and resorption. To test the hypothesis that a twice-daily PTH regimen can produce more physiological control than a once-daily regimen, we performed a randomized cross-over trial, lasting 28 weeks, in 17 adult subjects with hypoparathyroidism. Each 14-week study arm was divided into a 2-week inpatient dose-adjustment phase and a 12-week outpatient phase. The PTH dose (given sc once daily at 0900 h or twice daily with one dose at 0900 h and the other at 2100 h) was adjusted to maintain both serum and urine calcium within, or close to, the normal range. During the second half of the day (12-24 h), twice-daily PTH increased serum calcium and magnesium levels more effectively than once-daily PTH. In patients with calcium receptor mutations (CaR), once-daily PTH normalized urine calcium, provided that serum calcium was maintained at levels below normal range. However, twice-daily PTH treatment produced higher mean serum calcium in patients with CaR with no significant rise in urine calcium excretion, and with no significant differences in either serum or urine calcium levels between CaR and patients with acquired or idiopathic hypoparathyroidism. Thus, treatment with twice-daily PTH is the better regimen for patients with CaR to overcome their tendency to hypercalciuria while producing near-normal levels of serum calcium. The total daily PTH dose was markedly reduced with the twice-daily regimen (twice daily 46+/-52 vs. once daily 97+/-60 microg/day, P < 0.001). We conclude that a twice-daily PTH regimen provides effective treatment of hypoparathyroidism and reduces the variation in serum calcium levels at a lower total daily PTH dose.

Squamous cell carcinoma arising in an unhealed wound in Crohn's disease.

A 49-year-old black woman with a 23-year history of Crohn's disease came to our clinic; she had a squamous cell carcinoma arising in an unhealed perineal wound 16 years after abdominoperineal resection (APR). We report this case to show the potential for malignant degeneration in such wounds. This patient had had multiple procedures for fistulotomies and incision and drainage of abscesses and, ultimately, an APR. After the APR, she had a persistent perineal wound, which did not fully heal despite extensive local and systemic therapy. Our examination revealed a chronic wound involving the entire perineum and vagina, including the labia, both inguinal folds, and the intergluteal cleft. Biopsies showed moderately differentiated squamous cell carcinoma throughout. We believe healing may be impaired in patients who have Crohn's disease, with a significant risk of unhealed perineal wounds after APR. Chronic unhealing wounds may progress to carcinoma, and this propensity toward transformation may be increased by immunosuppression. Complaints of persistent pain and unhealing wounds in the absence of infection in patients with Crohn's disease suggest the possibility of malignancy and biopsy is recommended.