Splenic trauma, the way forward in reducing splenectomy: our 15-year experience.

INTRODUCTION: The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. METHOD: A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. RESULTS: There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. DISCUSSION AND CONCLUSION: AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.

Gallbladder polypoid lesions are inaccurately reported and undermanaged: a retrospective study of the management of gallbladder polypoid lesions detected at ultrasound in symptomatic patients during a 36-month period.

AIM: To investigate whether gallbladder polypoid lesions (GPL) are accurately reported and managed by radiologists, sonographers, general practitioners (GPs) and surgeons. MATERIALS AND METHODS: Consecutive abdominal ultrasound examinations indicating GPL in symptomatic patients performed during 2011-2013 were captured and analysed. The study comprised 244 patients who satisfied the inclusion criteria. RESULTS: Of the ultrasound reports retrieved, 238/244 reports (98%) erroneously described the polypoid lesions as polyps. One hundred and thirty-two of the 244 (54%) reports recommended follow-up, 5/244 (2%) recommended no follow-up, 35/244 (14%) deemed the findings insignificant, and 72/244 (30%) did not comment. Regarding GP referral, 57/184 (31%) patients were correctly referred to general surgeons, 20/184 (11%) to gastroenterologists, and 107/184 (58%) were not referred to secondary care. Forty-three of the 244 patients (18%) underwent cholecystectomy. Regarding subsequent biliary presentations, 63/244 patients (26%) presented at a later date with biliary symptoms; 13/63 (21%) of these eventually had cholecystectomies with 2/13 (15%) experiencing potentially life-threatening pancreatitis episodes. Regarding the surgical approach, differences were observed in the way individual surgeons managed polypoid lesions, with some veering towards cholecystectomy, others towards follow-up ultrasound, and some towards discharge. CONCLUSION: GPL tend to be misreported by radiologists and sonographers, unappreciated by GPs, and variably managed by surgeons. These factors delay definitive therapy and seem to contribute to future biliary presentations. A fresh educational approach is required to raise awareness among radiologists, sonographers, and GPs regarding the clinical relevance and possible representations of GPL, and a uniform strategy is needed for managing GPL.

Imaging protocol for suspected ureteric calculi in patients presenting to the emergency department.

AIM: To ensure diagnostic yields were adequate in patients with suspected ureteric calculi with and without haematuria, and to assess whether there was a significant difference between these two groups in men and women. MATERIALS AND METHODS: A retrospective analysis was undertaken of 513 patient records who attended the Emergency Department with suspected ureteric colic over 8 months. RESULTS: 513 patient records were evaluated. The overall positive rate for calculi was 45.4%, with an alternative diagnosis in 14.4%. Of the patients scanned with haematuria 49.36% were positive. The positive scan rate in males was significantly higher than in females (56% v. 31%, p < 0.0001). 32.79% of patients scanned without haematuria had a proven calculus. The positive rate in males without haematuria was 40.39% versus 27.14% in females. CONCLUSION: The overall diagnostic yield of 45.4% is acceptable according to national guidelines. A large number of patients scanned without haematuria were found to have a calculus. This review suggests that in males a negative urine dipstick should not preclude CT investigation for renal colic in the presence of a "classical" history. However, the number of female patients with negative scans suggests that further randomized studies are needed to identify the ideal investigation pathway in women.

Topical steroids for chronic wounds displaying abnormal inflammation.

INTRODUCTION: Chronic, non-healing wounds are often characterised by an excessive, and detrimental, inflammatory response. We review our experience of using a combined topical steroid, antibiotic and antifungal preparation in the treatment of chronic wounds displaying abnormal and excessive inflammation. METHODS: A retrospective review was undertaken of all patients being treated with a topical preparation containing a steroid (clobetasone butyrate 0.05%), antibiotic and antifungal at a tertiary wound healing centre over a ten-year period. Patients were selected as the primary treating physician felt the wounds were displaying excessive inflammation. Healing rates were calculated for before and during this treatment period for each patient. Changes in symptom burden (pain, odour and exudate levels) following topical application were also calculated. RESULTS: Overall, 34 ulcers were identified from 25 individual patients (mean age: 65 years, range: 37-97 years) and 331 clinic visits were analysed, spanning a total time of 14,670 days (7,721 days 'before treatment' time, 6,949 days 'during treatment' time). Following treatment, 24 ulcers demonstrated faster rates of healing, 3 ulcers showed no significant change in healing rates and 7 were healing more slowly (p=0.0006). Treatment generally reduced the burden of pain and exudate, without affecting odour. CONCLUSIONS: In normal wound healing, inflammation represents a transient but essential phase of tissue repair. In selected cases, direct application of a steroid containing agent has been shown to improve healing rates, presumably by curtailing this phase. Further evaluation is required to establish the role of preparations containing topical steroids without antimicrobials in the management of chronic wounds.

Cardiac ischaemia and rhythm disturbances during elective colonoscopy.

BACKGROUND: The number of colonoscopic procedures continues to rise rapidly. With widespread adoption of colonoscopy based bowel screening programmes, this rising trend is set to continue. AIMS: This study aimed to identify whether elective colonoscopy could provoke cardiac rhythm disturbances and/or myocardial ischaemia, as evidenced by 12 lead Holter ECG recordings and troponin I (cTnI) changes. MATERIALS AND METHODS: Patients were stratified into three groups based on the presence of cardiac disease or cardiovascular risk factors. They underwent real time 12 lead Holter monitoring before, during and after colonoscopy. Bloods were taken for pre- and post-procedure cTnI estimation. RESULTS: Holter ECG recordings of the three groups showed a high incidence of new but silent ischaemic and arrhythmic ECG changes during the colonoscopy in patients with documented but stable heart disease and to a lesser extent in those patients with one or more risk factors for heart disease. Three patients had high cTnI concentrations both before and after colonoscopy. Two patients with known heart disease died within 30 days of colonoscopy. CONCLUSIONS: This study demonstrates for the first time the occurrence of potentially clinically significant ST-T wave changes and rhythm disturbances during elective colonoscopy in patients with known heart disease and to a lesser extent in those patients with a known cardiovascular risk profile.

Facial scarring after varicella. A comparison with variola major and variola minor.

To assess the prevalence of persistent facial scars after recovery from chickenpox (varicella), 250 subjects in Somalia in whom the diagnosis had been confirmed by electron microscopic identification of varicella virus were examined in 1979, a year after their illness; 2.4% had five or more facial scars indistinguishable from those seen among smallpox (variola major or variola minor) victims, with a higher percentage among males (2.7%) than females (1.9%). The highest proportion of those with five or more residual facial scars (8.3%) was found among young adults 20-29-years-old. The low proportion of varicella cases who had five or more facial scars contrasts with the 6.8% of cases of variola minor who were similarly scarred one year later (Somalia, 1978), and to an even greater degree with the situation after variola major, where the proportion varied from 65% for vaccinated subjects to 85% among unvaccinated persons (India, 1976). Pockmark surveys are a valid method for determining the past occurrence of variola major but cannot be relied on in areas were variola minor has occurred. However, varicella must be considered when making such a retrospective diagnosis.