Correlation of rib fracture patterns with abdominal solid organ injury: A retrospective observational cohort study.

PURPOSE: Rib fractures are one of the most common causes of morbidity and mortality and are associated with abdominal solid organ injury (ASOI). The purpose of this study was to investigate the correlation of ASOI with the number, location, and involved segments of rib fracture(s) in blunt chest trauma. METHODS: This retrospective cohort study was conducted on patients with blunt chest trauma over the age of 15 years, who were hospitalized with the diagnosis of rib fractures from July 2015 to September 2020. After ethic committee approval, a retrospective chart review was designed and patients with a diagnosis of rib fractures were selected. Patients who had chest and abdominopelvic CT scan were included in the study and additional data including age, gender, injury severity score, trauma mechanism, number and sides of the fractured ribs (left/right/bilateral), rib fracture segments (upper, middle, lower zone) and results of chest and abdominal spiral CT scan were recorded. The correlation between ASOI and the sides, segments and number of rib fracture(s) was assessed by Pearson's correlation coefficient. RESULTS: Altogether 1056 patients with rib fracture(s) were included. The mean age was (42.76 ± 13.35) years and 85.4% were male. The most common mechanism of trauma was car accident (34.6%). Most fractures occurred in the middle rib zone (60.44%) and the most commonly involved ribs were the 6th and 7th ones (15.7% and 16.4%, respectively). Concurrent abdominal injuries were observed in 103 patients (34.91%) and were significantly associated with middle zone rib fractures. CONCLUSION: There is a significant relationship between middle zone rib fractures and ASOI. Intra-abdominal injuries are not restricted to fractures of the lower ribs and thus should always be kept in mind during management of blunt trauma patients with rib fractures.

Implementation of an algorithm for chest imaging in blunt trauma decreases use of CT-scan: Resource management in a middle-income country.

PURPOSE: Due to the low sensitivity of chest radiography, chest CT-scan is usually recommended for the evaluation of high-risk blunt trauma patients. Considering the radiation exposure and costs accompanying routine CT-scan, the aim of this study was to design and implement an evidence-based institutional algorithm for selective chest imaging in high energy blunt trauma patients and evaluate its effect on patient outcome and resource utilization. METHODS: For this field trial, an institutional evidence-based algorithm for chest trauma imaging was designed according to existing data and expert panel. After final consent and ethic committee approval, the algorithm was integrated in the diagnostic flow sheet in the emergency department and patient data were collected from the pre- and post-implementation period. RESULTS: One-hundred and sixty-five patients before algorithm implementation and 158 patients after that were included. Chest CT-scan was requested for 93% of patients in the pre-implementation group and for 73% in the post-implementation group (P<0.001). Length of stay in hospital was slightly shorter in the post-implementation group (p = 0.036), however, duration of stay in emergency room and ICU, pulmonary complications and mortality showed no significant difference. CONCLUSION: Implementation of an algorithm for limiting chest CT-scan to a subgroup of patients with a higher risk of chest injuries can reduce radiation exposure and more useful distribution of resources without harming the patients. Each institution should use institutional guidelines and algorithms with respect to patient load, available resources and desired sensitivity for injury detection.

Transhiatal Esophagectomy after Previous Left Pneumonectomy: Challenge of Surgical Approach, a Case Report.

The occurrence of esophageal cancer after previous pneumonectomy for primary lung cancer is rare. This is the second case report of transhiatal esophagectomy after previous pneumonectomy due to lung cancer. In this case, selection of surgical approach for esophagectomy, was technically challenging and anatomic deformity in post pneumonectomy space had potential risk of physiologic disturbance, especially after thoracotomy option in solitary lung with limited capacity. CASE PRESENTATION: We herein report a 58 year old man with history of left pneumonectomy and lymph node dissection due to mucoepidermoid carcinoma 19 years ago and recently admitted for esophageal carcinoma. He successfully was managed via transhiatal approach. CONCLUSION: Transhiatal esophagectomy in pneuminectomized patient is safe and recommended as first option.

Combination adjunctive nebulized furosemide and salbutamol versus single agent therapy in COPD patients: A randomized controlled trial.

BACKGROUND: COPD patients often require multiple therapies to enhance their lung function and reduce their symptoms in exacerbations. This study aimed to investigate the relative effects of combination adjunctive nebulized furosemide and salbutamol therapy versus single agent treatment in COPD patients. METHODS: Sixty-nine COPD patients were randomly divided into two groups. The first group (G1, 34 cases) received salbutamol in their first episode. The second group (G2, 35 cases) received furosemide in their first episode. Spirometry indices (FEV1, FVC, and FEV1/FVC), mMRC and BORG (COPD assessment) were assessed and recorded for all patients.To study the efficacy of combination adjunctive therapy, in 2nd episodes, the nebulized furosemide was added to nebulized salbutamol in the G1, and nebulized salbutamol was added to nebulized furosemide in G2. The aforementioned indices were then re-assessed. RESULTS: The mean age was (64.92 ± 11.71 years, 55% males. The use of nebulized furosemide and salbutamol as single agents slightly improved the spirometeric parameters, but it was not noteworthy compared to the significant improvement of the FEV1, FVC, FEV1/FVC, mMRC, and Borg parameters with combination therapy (p-value< 0.001). In the first episode, there was no difference in spirometeric indices, between groups (p-value > 0.1), so furosemide is considered as effective as nebulized salbutamol. Also, the results of sequential drugs administration, in the two groups was similar. CONCLUSION: Conjunction of nebulized furosemide and salbutamol is more effective than single therapy and can be considered as preferred drug regimen without any reported side effect in the treatment of COPD.

Optimizing cholecystectomy time in moderate acute biliary pancreatitis: A randomized clinical trial study.

BACKGROUND: In mild to moderate gallstone pancreatitis, cholecystectomy is the most appropriate treatment for prevention of further biliary attacks. However, the timing of cholecystectomy is not precisely determined. The present study was conducted to compare outcomes of very early (within 48 h) versus delayed (more than 1 week) laparoscopic cholecystectomy in patients with acute biliary pancreatitis (ABP). METHODS: This randomized clinical trial study was conducted in Shahid Beheshti Hospital of Kashan University of Medical Sciences from September 2016 to Mar 2019. Two hundred and eight cases with mild to moderate ABP were randomly assigned to 2 groups, with 104 patients in group 1 (operation within 48 h) and 104 in group 2 (operation after one week). Age, sex, biochemical parameters, clinical manifestation at the time of admission, operation time, recurrent biliary problems, relapse, peri-operative complications, conversion rate, and hospital length of stay in the two groups were recorded and compared. In addition, Ranson's score and Revised Atlanta criteria, the American Society of Anaesthesiologists Physical Status ASA-PS, Charlson Co-Morbidity Index (CCI), complexity of surgery and Clavien-Dindo score were also determined. RESULTS: There were no differences in demographics, peri-operative complications 4 (4%) vs. 4 (4%), P = 1), conversion rate (10.6% vs. 11.5%; P = 0.825) and procedure time (83 vs. 81 minutes, P = 0.110) between the two groups. There were no deaths in either group; however, the length of hospital stay was shorter in the early group compared to the delayed one, (3.66 ± 1.12 vs. 10.35 ± 1.76, P < 0.001). CONCLUSION: Cholecystectomy within 48 h decreases significantly the length of hospital stay, without any difference in conversion rate, procedure time, or complication rate.

Acute purulent mediastinitis with sequential bilateral pleural empyema caused by neck trauma: A unique occurrence, a case report.

BACKGROUND: Descending necrotizing mediastinitis (DNM) due to blunt trauma is very rare form of mediastinitis that can rapidly progress to septicemia and multi organ failure, in spite of optimal surgical management. CASE PRESENTATION: We report a 28-year-old patient, previously healthy man, with acute descending necrotizing mediastinitis and late sequential bilateral pleural empyema, caused by blunt neck trauma. Although after admission, the course of his illness was complicated with septic shock, homodynamic instability, renal and pulmonary insufficiency, however he survived with on time diagnosis, aggressive surgical intervention, appropriate antibiotics administration and optimal management in the intensive care unit (ICU). CONCLUSIONS: Descending necrotizing mediastinitis due to blunt neck trauma is a rare occurrence, but can lead to late sequential bilateral empyema even after 18 days. With early diagnosis, aggressive drainage and antibiotic therapy, the patient life can be saved. The lesson we took from this case is that: 1- blunt neck trauma rarely leads to descending necrotizing mediastinitis and late sequential empyema (even after 18 days). 2- If the patient does not recover from sepsis, despite optimal surgical management, contra lateral empyema or pericarditis should be considered.

Melatonin as a potential inhibitor of colorectal cancer: Molecular mechanisms.

Colorectal cancer (CRC) is a prevalent disease and a major cause of mortality in the world. Several factors including population aging, poor dietary habits, obesity, insufficient physical activity, and smoking can explain its increased prevalence. CRC is a heterogeneous disease both histopathologically and in term of its molecular and genetic aspects. Melatonin a derivative of tryptophan, is synthesized and released from pineal gland but it is also found in numerous extrapineal tissues including retina, testes, lymphocytes, Harderian gland, gastrointestinal tract, etc. This molecule has several tasks which enhance physiological functions such as antioxidant, antiaging, immunomodulatory, and tumor inhibition. Multiple immunocytochemical studies reported melatonin in the intestinal mucosa where its concentration is greater than in the blood. These findings suggest that melatonin may have a potential inhibitory role in CRC progression. The purpose of this review is to examine the effects of melatonin in molecular pathogenesis and signaling pathways of CRC.

Melatonin and non-small cell lung cancer: new insights into signaling pathways.

Non-small-cell lung cancer (NSCLC) is a type of malignancy with progressive metastasis having poor prognosis and lowered survival resulting from late diagnosis. The therapeutic approaches for the treatment of this incurable cancer are chemo- and radiotherapy. Since current treatments are insufficient and because of drug-induced undesirable side effects and toxicities, alternate treatments are necessary and critical. The role of melatonin, produced in and released from the pineal gland, has been documented as a potential therapy for NSCLC. Melatonin prevents tumor metastasis via inducing apoptosis processes and restraining the autonomous cell proliferation. Moreover, melatonin inhibits the progression of tumors due to its oncostatic, pro-oxidant and anti-inflammatory effects. As a result, the combined treatment with melatonin and chemotherapy may have a synergistic effect, as with some other tumors, leading to a prolonged survival and improved quality of life in patients with NSCLC. This review summarizes the available data, based on the molecular mechanisms and related signaling pathways, to show how melatonin and its supplementation function in NSCLC.

Isolated Common Hepatic Artery Branch Thrombosis: Results and Risk Factors.

Isolated common hepatic artery branch thrombosis with severe gastric ischemia and duodenojejunal infarction is a rare condition; it usually presents with acute abdomen and may be associated with underlying thrombotic risk factors. We present a 35-year-old man admitted to our hospital with five days history of sudden abdominal pain and deteriorating epigastric pain. He was a driver and had no any past medical history. Explorative laparotomy showed: distal 2/3 gastric, duodenojejunal and papilla vater was sloughed. The stomach subtotal and sloughed duodenum and first 20 cm of jejunum were resected, continuity of the gastrointestinal was preserved with anastomosis of the proximal part of jejunum to gastric stump, pancreatic duct, and CBD repaired to the lateral side of jejunum on the guide of two 18 French feeding tube as an external drain. The patient had a good immediate postoperative recovery. Coagulation checkup after operation revealed isolated Hyperhomocysteinemia.

Substrate-Dependent Activity of ERK and MEK Proteins in Breast Cancer (MCF7), and Kidney Embryonic (Hek-293) Cell Lines, Cultured on Different Substrates.

BACKGROUND: Breast cancer has been one of the most common types of cancer, as the leading cause of women death in world. Breast cancer has known as a heterogenic disease that the clinical path in different patients would be very different. Since the current classification has not covered the diverse clinical course of breast cancer, lots of efforts has done to find new biological markers. Integrins are hetero dimmer proteins of α and ß subunits on cell membrane. After binding to extra cellular matrix (ECM), integrins activate MAPK pathway that regulated different activities like survival, differentiation, migration, immunologic response. The interaction of integrins and ECM have a key role in cancer cell activities like survival and metastasis. OBJECTIVES: In this study the expression of αvß3 integrin, substrate -dependent morphology and ERK and p-ERK activation was compared in MCF7 and Hek-293 cells lines. MATERIALS AND METHODS: The expression of αvß3 integrin was assayed by flow cytometry. These cell lines were cultured on pre-covered plates with fibronectin (FN), fibrinogen (Fg) or collagen (Col) and the expression of ERK and p-ERK proteins was assessed in attached and free cells for each substrate after 1 hour incubation. The morphology of the cells have examined under an inverted phase contrast microscope at 15 min, 1 hour, 3 hours, 5 hours and 1 day of incubatioon. RESULTS: Different substrate induced the expression ERK or p-ERK differently in the two cell lines. In MCF7 cells, substrates induced the expression of ERK in all the attached cells but free cells in BSA, collagen and Fg showed a lower expression of ERK. In comparison with Hek-293 cells althought all the attached cells have expressed ERK peotein but only free cells in collagen plates showed the expression of ERK. None of the cell lines has shown any expression of ERK and p-ERK in attached or free cells except for the Hek-293 free cells in collagen platees that have shown a weak signal for p-ERK. CONCLUSIONS: Overall the breast cancer cell lines MCF7 and Hek-293 cells have differently responded on similar substrates regarding morpology or ERK and MEK expressions.

Invading of intrauterine contraceptive device into the sigmoid colon through uterine perforation caused by a blunt trauma.

Intrauterine contraceptive device (IUCD) is relatively safe but still with some serious risks. Uterus perforation is rare and would be fatal. A case of Cu-7 IUCD invading into the sigmoid colon through uterine perforation caused by a pelvic blunt trauma was presented. Our case showed that uterus perforation by an IUCD could induce utero-sigmoid fistula which is likely to be missed. Imaging is required when the patients with IUCD present abdominal pain, particularly with a history of trauma.