Handlebar Injuries: Not Always the Pancreas.

This case report highlights a rare traumatic gallbladder rupture secondary to a handlebar impact to the abdomen. Traumatic gallbladder rupture is only seen in 1.9-2.1% of all reported abdominal trauma. The diagnosis can be delayed due to the rarity of injury and the non-specific symptoms that a patient may present with. This case highlights the need for high clinical suspicion based on the mechanism of injury and imaging studies (focused assessment with sonography (FAST) and computed tomography (CT) scan) to direct treatment of concurrent injuries to assure the best outcome and prevent complications and morbidity. This patient was treated surgically with cholecystectomy and was discharged in stable condition.

Sprengel deformity presenting as a post-traumatic injury in an afghan boy: a case report.

Sprengel deformity is a rare congenital anomaly that involves the shoulder joint and scapula. We treated a young Afghan boy who was presented to the German Level II Provincial Reconstructive Team in Kunduz, Afghanistan, with the complaint of a shoulder deformity evolving after an accident that occurred several years before the presentation of the patient to clinic. Physicians maximized the available resources for the diagnostic workup by arranging for his computed tomography scan at the German Level III Hospital at Mazar-e-Sharif and then reviewing the study through teleradiology. The presence of a Coalition Surgical Team allowed the delivery of advanced surgical care by combining the specialized surgical skills of three upper extremity surgeons deployed to the area.

Enhanced enzymatic degradation of tryptophan by indoleamine 2,3-dioxygenase contributes to the tryptophan-deficient state seen after major trauma.

Decreased lymphocyte proliferation, lymphopenia, immunodepression, and opportunistic infections are common after major trauma. Early alimentation in these patients corrects lymphopenia, enhances immunity, and reduces the incidence of infections, but the underlying mechanisms are poorly understood. Tryptophan is essential for the production and function of rapidly proliferating cells such as lymphocytes. Tryptophan is enzymatically degraded by indoleamine 2,3-dioxygenase (IDO), whose activity is solely dependent on expression of interferon-gamma (IFN-gamma). Because increased expression of IFN-gamma has been reported in trauma patients, we investigated whether enhanced IDO-mediated tryptophan degradation is associated with lymphopenia and poor outcomes after major trauma. The incidence of bacteremic sepsis (BS), adult respiratory distress syndrome (ARDS), multiple organ dysfunction/failure syndromes (MODS/MOF), and death was prospectively documented in 22 trauma patients with a mean ISS of 24.9 +/- 2.2. Sequential blood samples were obtained from admission through postinjury day 10. Five patients developed BS, three of whom developed ARDS; two of the three ARDS patients developed MOF and died on day 10. Trauma patients had significantly lower tryptophan levels (days 1-10), higher kynurenine:tryptophan ratios (days 1-2), and fewer lymphocytes (days 1-4) than healthy volunteers (P < 0.05). Although patients with poor outcomes (i.e., BS, ARDS, MOF, and death) had significantly lower tryptophan levels and greater lymphopenia on several days after injury, the sample size was too small to draw any definitive conclusions. These data indicate that decreased plasma tryptophan levels and lymphopenia typically occur after major trauma. A concomitant increase in kynurenine suggests that the observed tryptophan deficiency is caused, in part, by IDO-mediated tryptophan degradation.