Proximal Versus Distal Splenic Artery Embolisation for Blunt Splenic Trauma: What is the Impact on Splenic Immune Function?

PURPOSE: To compare the impact of proximal or distal splenic artery embolisation versus that of splenectomy on splenic immune function as measured by IgM memory B cell levels. MATERIALS AND METHODS: Patients with splenic trauma who were treated by splenic artery embolisation (SAE) were enrolled. After 6 months splenic volume was assessed by CT, and IgM memory B cells in peripheral blood were measured and compared to a local normal reference population and to a post-splenectomy population. RESULTS: Of the 71 patients who underwent embolisation, 38 underwent proximal embolisation, 11 underwent distal embolisation, 22 patients were excluded, 1 had both proximal and distal embolisation, 5 did not survive and 16 did not return for evaluation. There was a significant difference between splenectomy and proximal or distal embolisation and a trend towards greater preservation of IgM memory B cell number in those with distal embolisation-a difference that could not be attributed to differences in age, grade of injury or residual splenic volume. CONCLUSION: IgM memory B cell levels are significantly higher in those treated with SAE compared to splenectomy. Our data provide evidence that splenic embolisation should reduce immunological complications of spleen trauma and suggest that distal embolisation may maintain better function.

Multi-detector CT angiography for lower gastrointestinal bleeding: Can it select patients for endovascular intervention?

This is a retrospective review of the results at our institution of using multi-detector CT angiography (CTA) to localise lower gastrointestinal (GI) bleeding. We hypothesised that in our patient population: (i) CTA was unlikely to demonstrate bleeding in patients who were haemodynamically stable; (ii) in haemodynamically unstable patients in whom CTA was undertaken, the results could be used to select patients who would benefit from catheter angiography; and (iii) in haemodynamically unstable patients in whom CTA was undertaken, a subgroup of patients could be identified who would benefit from primary surgical treatment, avoiding invasive angiography completely. A retrospective review was conducted of the clinical records of all patients undergoing CTA for lower GI haemorrhage at our institution between 1 January 2005 and 30 June 2007. Out of the 20 patients examined, 10 had positive CTAs demonstrating the bleeding site. Nine were haemodynamically unstable at the time of the study. Four patients with positive CT angiograms were able to be treated directly with surgery and avoided invasive angiography. Ten patients had negative CTAs. Four of these were haemodynamically unstable, six haemodynamically stable. Only one required intervention to secure haemostasis, the rest stopped spontaneously. No haemodynamically stable patient who had a negative CTA required intervention. CTA is a useful non-invasive technique for localising the site of lower GI bleeding. In our patient population, in the absence of haemodynamic instability, the diagnostic yield of CTA was low and bleeding was likely to stop spontaneously. In haemodynamically unstable patients, a positive CTA allowed patients to be triaged to surgery or angiography, whereas there was a strong association between a negative CTA and spontaneous cessation of bleeding.

How I do it: Lymphangiography.

Lymphangiography, despite advances in cross-sectional imaging, remains a useful tool in the diagnosis and therapeutic intervention of lymphatic vessel damage, such as high output chylothorax. This article describes our technique for this procedure.

Fibromuscular dysplasia presenting with bilateral renal infarction.

Fibromuscular dysplasia (FMD) describes a group of conditions which cause nonatheromatous arterial stenoses, most commonly of the renal and carotid arteries, typically in young women. We report a rare case of bilateral segmental renal infarction secondary to FMD in a young male patient. His initial presentation with loin pain and pyrexia resulted in a delay in the definitive diagnosis of FMD. He was successfully treated with bilateral balloon angioplasty. The delayed diagnosis in this patient until the condition had progressed to bilateral renal infarcts highlights the need for prompt investigation and diagnosis of suspected cases of FMD.

Is conservative management of prenatal and neonatal ovarian cysts justifiable?

OBJECTIVES: To evaluate conservative management of fetal and neonatal ovarian cysts. METHODS: We followed the progress of 11 fetal and 2 neonatal ovarian cysts. RESULTS: Ten fetal cysts were simple at recognition, but 8 silently became complex by birth, with ovarian loss in 6/11 cases (54%). In 2 cases where large simple cysts presented for the first time at birth, serious complications occurred, resulting in the death of 1 newborn. CONCLUSIONS: If a fetal ovarian cyst is already complex before birth it can be managed conservatively, albeit with loss of the ipsilateral ovary in the majority of cases. As simple fetal ovarian cysts frequently become complex before birth, intervention may be justifiable to preserve the ovary. But any intervention also has the potential for complications, and may be ineffective. Intervention also requires accurate differentiation of ovarian cysts from other abdominal cysts.

Radiological digital teaching file development: an overview.

Radiologists are collectors of interesting films for teaching purposes or for use in presentations and publications. Traditionally, hard copies of films have been stored in an organized fashion, usually in a filing cabinet or film library. This system has inherent limitations, such as the physical space required. Many of the shortcomings can be circumvented by development of an electronic teaching file. Whereas the implementation of an institutional radiological digital image database can require significant developmental effort and programming expertise, there are a number of web-based solutions which are freely available and can be relatively easily employed to establish a contemporary electronic image library. This article will review the various options and discuss the process of developing a digital image database.

Urogenital nonunion--the case for laparoscopy for the impalpable testis.

A case of urogenital nonunion is presented to illustrate the importance of laparoscopy for the impalpable testis. A 4-year-old boy with an impalpable left testis underwent laparoscopy. This revealed not only the vas deferens entering the deep inguinal ring but also a small intraabdominal testis supplied by the testicular vessels. Exploration of the inguinal canal revealed the vas deferens terminating in a nubbin of tissue. Histology identified epididymal structures both adjacent to the testis and in the terminal nubbin of the vas deferens. This is an example of urogenital nonunion. Complete separation of the vas and testis with epididymal structures attached to each is very unusual, with only four other cases reported. Laparoscopy should be the initial procedure for impalpable testis. A blind-ending vas deferens found on exploration of the inguinal canal might be taken as evidence of the vanishing testis syndrome. However, this conclusion should not be drawn unless laparoscopy has demonstrated testicular vessels entering the internal inguinal ring.

Enteric duplications presenting as antenatally detected abdominal cysts: is delayed resection appropriate?

PURPOSE: The aim of this study was to evaluate delayed elective resection of antenatally detected enteric duplication cysts. METHODS: A retrospective casenote study of intraabdominal cysts detected antenatally between January 1991 and January 2002 found 37 fetuses with cysts. Twelve were enteric duplications. Two were duodenal, 1 was an 85-cm tubular jejunoileal duplication, and 9 were ileocecal. Asymptomatic cysts were followed with serial ultrasound scars and resected electively over 14 months. RESULTS: Three neonates had small bowel obstruction demanding laparotomy: 1 of the 2 infants with duodenal duplication cysts, 1 infant with an ileocecal duplication, and the infant with the tubular duplication. One with an ileocecal duplication became symptomatic at 2 months and underwent a laparotomy. Seven had their duplications resected electively between 6 weeks and 14 months, and the other is still being followed. Four of the 7 asymptomatic duplications electively resected contained gastric mucosa. CONCLUSIONS: Intraabdominal enteric duplication cysts are increasingly likely to be detected antenatally. The majority are likely to remain asymptomatic for several months at least, after which a resection can be planned. The prevalence of gastric mucosa suggests that they should not be left indefinitely. Laparoscopically assisted resection of ileocecal duplications is safe and effective.

Multidimensional work sampling to evaluate the effects of computerization in an outpatient pharmacy.

The effectiveness of multidimensional work sampling versus direct observation in evaluating the effects of computerization in an outpatient pharmacy was studied. A direct-entry, self-reporting method of multidimensional work sampling was used to measure and compare the relative times spent on various tasks before and after computerization in the outpatient pharmacy of a 475-bed teaching hospital. Analysis of variance was used to evaluate differences in the types of functions performed, differences in functions among the five employees (two pharmacists, one pharmacy intern, and two technicians), and differences in functions on a week-to-week basis. Data obtained by multidimensional work sampling were compared with data obtained by direct observation to determine the level of agreement between the two methods. Also, a time clock method was used to measure and compare the time required for prescription processing before and after computerization. After computerization, the percentage of time spent on some clerical tasks decreased by 26.7%, but this decrease was offset by a significant increase of 27.7% in the percentage of time spent entering information into the computer. Time spent on clinical tasks did not change significantly. A significant difference among employees was found in the percentage of time spent on clinical functions. The differences in time spent on clinical or clerical functions from week to week were not significant. The time to process a set of prescriptions increased after computerization, primarily because of the time needed to enter information into the computer. However, computerization enabled the generation of patient profiles. Multidimensional work sampling is an accurate method of work measurement that may be more useful than direct observation in capturing clinical functions.

Compatibility of clindamycin phosphate with cefotaxime sodium or netilmicin sulfate in small-volume admixtures.

The stability and compatibility of clindamycin phosphate plus either cefotaxime sodium or netilmicin sulfate in small-volume intravenous admixtures were studied. Admixtures containing each drug alone and two-drug admixtures of clindamycin phosphate plus cefotaxime sodium or netilmicin sulfate were prepared in 100 mL of 5% dextrose injection and 0.9% sodium chloride injection in both glass bottles and polyvinyl chloride (PVC) bags. Final concentrations of clindamycin, cefotaxime, and netilmicin were 9, 20, and 3 mg/mL, respectively. All solutions were prepared in duplicate and stored at room temperature (24 +/- 2 degrees C). Samples were visually inspected, tested for pH, and assayed for antibiotic concentration using stability-indicating assays at 0, 1, 4, 8, 16, and 24 hours for admixtures in glass bottles and at 0, 8, and 24 hours for admixtures in PVC bags. No substantial changes in color, clarity, pH, or drug concentration were observed in any of the solutions. Clindamycin phosphate is compatible with cefotaxime sodium or netilmicin sulfate in 5% dextrose and 0.9% sodium chloride injections in glass bottles or PVC bags for 24 hours.