[Successful preclinical thoracotomy in a 17-year-old man]. / Erfolgreiche präklinische Thorakotomie bei einem 17-jährigen Mann.

We report the case of a 17-year-old man who sustained multiple stab wounds after a knife attack. After arrival of the emergency medical team the patient suffered a cardiac arrest caused by cardiac tamponade. After emergency thoracotomy and open heart massage the patient developed ROSC and could be discharged 13 days later without neurological deficits. Prehospital thoracotomy is rarely performed in Austria but is the only realistic chance for survival in cases of hematopericardium and tamponade. Better training of emergency physicians in Austria concerning surgical resuscitation could increase survival rates especially after penetrating thoracic trauma.

The three-dimensional morphometry of the odontoid peg and its impact on ventral screw osteosynthesis.

Ventral screw osteosynthesis is a common surgical method for treating fractures of the odontoid peg, but there is still no consensus about the number and diameter of the screws to be used. The purpose of this study was to develop a more accurate measurement technique for the morphometry of the odontoid peg (dens axis) and to provide a recommendation for ventral screw osteosynthesis. Images of the cervical spine of 44 Caucasian patients, taken with a 64-line CT scanner, were evaluated using the measuring software MIMICS. All measurements were performed by two independent observers. Intraclass correlation coefficients were used to measure inter-rater variability. The mean length of the odontoid peg was 39.76 mm (SD 2.68). The mean screw entry angle α was 59.45° (SD 3.45). The mean angle between the screw and the ventral border of C2 was 13.18° (SD 2.70), the maximum possible mean converging angle of two screws was 20.35° (SD 3.24). The measurements were obtained at the level of 66% of the total odontoid peg length and showed mean values of 8.36 mm (SD 0.84) for the inner diameter in the sagittal plane and 7.35 mm (SD 0.97) in the coronal plane. The mean outer diameter of the odontoid peg was 12.88 mm (SD 0.91) in the sagittal plane and 11.77 mm (SD 1.09) in the coronal plane. The results measured at the level of 90% of the total odontoid peg length were a mean of 6.12 mm (SD 1.14) for the sagittal inner diameter and 5.50 mm (SD 1.05) for the coronal inner diameter. The mean outer diameter of the odontoid peg was 11.10 mm (SD 1.0) in the sagittal plane and 10.00 mm (SD 1.07) in the coronal plane. In order to calculate the necessary screw length using 3.5 mm cannulated screws, 1.5 mm should be added to the measured odontoid peg length when anatomical reduction seems possible. The cross-section of the odontoid peg is not circular but slightly elliptical, with a 10% greater diameter in the sagittal plane. In the majority of cases (70.5%) the odontoid peg offers enough room for two 3.5 mm cannulated cortical screws.

Role of N-terminal pro B-type natriuretic peptide in identifying patients at high risk for adverse outcome after emergent non-cardiac surgery.

BACKGROUND: Patients undergoing emergency surgery continue to be at very high risk, but accurate risk identification for the individual patient remains difficult. This study tested the usefulness of perioperative N-terminal pro B-type natriuretic peptide (NT-proBNP) for in-hospital and long-term risk stratification. METHODS: We conducted a prospective single-centre observational cohort study in an Austrian university hospital. Two hundred and ninety-seven consecutive patients >50 yr of age undergoing a variety of emergency non-cardiac procedures were included. The primary endpoint was a composite of non-fatal myocardial infarction (MI), acute heart failure, or death between index surgery and 3 yr follow-up. The secondary endpoint was in-hospital major adverse cardiac events (MACE), defined as non-fatal MI, acute heart failure, or cardiac death. RESULTS: During a median follow-up of 34 months (inter-quartile range: 16-39), 31% of subjects reached the primary endpoint. A preoperative NT-proBNP ≥725 pg ml(-1) was associated with a 4.8-fold univariate relative risk [95% confidence interval (CI): 3.1-7.6] and a postoperative NT-proBNP ≥1600 pg ml(-1) was associated with a four-fold univariate relative risk (95% CI: 2.7-6.2) for reaching the primary endpoint. Moreover, preoperative NT-proBNP remained a significant and independent (hazards ratio 1.91, 95% CI 1.08-3.37, P=0.027) predictor in a multivariate Cox proportional hazards model. A preoperative NT-proBNP ≥1740 pg ml(-1) was associated with a 6.9-fold univariate relative risk (95% CI: 3.5-13.4) for MACE during the index hospital stay, but did not remain significant in a multivariate logistic regression model. CONCLUSIONS: Preoperative NT-proBNP can help identify patients at high risk for adverse long-term outcome after emergency surgery.

Medical audit data: counting is not enough.

OBJECTIVE: To assess the meaningfulness of a year's worth of audit data relating to all the inpatients of one consultant general surgeon and to question the usefulness of certain outcome measures. DESIGN: Analysis of records entered on to audit computer (Dunnfile) and relating to inpatient episodes for one consultant general surgeon over one year. Data obtained were compared with ward records and the patient administration system to check their accuracy. SETTING: The three hospitals and 12 wards in Brighton health district where the surgeon admitted patients. SUBJECTS: 859 Records relating to inpatient episodes from 1 January to 31 December 1988. These covered 655 main procedures and 79 secondary procedures performed at the same time. MAIN OUTCOME MEASURES: Procedures were analysed by complexity of operation (BUPA code) and grade of surgeon; complications were counted and rates constructed by surgeon and by BUPA code: returns to theatre were analysed. RESULTS: Simple counts revealed some data, such as the fact that one registrar performed more major operations (32) than the senior registrars (22 and 14), and an analysis of complications showed that he had a lower complication rate (11.4% v 20.0% and 19.4%). But the simple complication rate disclosed nothing about whether the complication was avoidable. Likewise, the number of returns to theatre needed further qualification. Analysis of data collection for February to April 1988 showed a 30% deficit of information on the audit system compared with ward records and prompted a re-examination of everyone's role in collecting data. After the year's audit there was still a 17% shortfall compared with the district's patient administration system, though some of this was accounted for by a backlog of work. CONCLUSIONS: It is difficult to ensure adequate data collection and entails everyone in an unfamiliar discipline. Connecting the audit system to the patient administration system would help. Despite the limitations of crude analyses of workload and complications rates, the audit data helped to measure activity and in the management of the firm. Nevertheless, time and care have to be taken in presenting and interpreting audit data carefully. IMPLICATIONS: Counting is not enough.

Regulation of insulin and glucagon secretion from a human islet cell adenoma.

The regulation of insulin biosynthesis, and insulin and glucagon secretion have been investigated in a human islet cell adenoma, by incubation of tumour fragments. Both biosynthesis and secretion of insulin were strongly stimulated by incubation of islet tumour cells in the presence of increasing glucose concentrations in the range 2-8 mmol/1. However, 20 mM-glucose or 20 mM-glucose plus isobutyl methylxanthine (IBMX), both of which provide potent secretagogues for normal B cells, failed to stimulate proinsulin biosynthesis and secretion from the tumour cells. Overall rates of secretion, expressed as a proportion of total insulin content, were up to 20-fold higher than those expected for normal pancreatic tissue. Glucagon secretion from the tumour was stimulated by low glucose concentrations; normal A cells also respond in this way under these conditions. However, no stimulation of glucagon secretion occurred in the presence of IBMX. There was therefore a major alteration in the regulation both of insulin and glucagon secretion, in that release of neither hormone was stimulated by cyclic AMP. Ultrastructural examination showed the tumour to be rather heterogeneous. A and B cells with normal storage granule content and structure were seen, as well as a rather larger number of B cells containing some granules of atypical appearance. The insulin content of the tumour (13 i.u./g wet wt) was consistent with 6-8% of the tumour cells being B cells.