Management of isolated splenic injuries after blunt trauma: an institution's experience over 6 years.

Forty-two patients with traumatic blunt splenic injuries were admitted over a six year period. Vehicular-related collisions and fall from height accounted for the injuries in 38 (90.5%) of them. Eleven (26.2%) underwent immediate surgery (7 splenectomy and 4 splenorrhaphy), while the remaining 31 patients were treated nonoperatively of which 3 underwent angio-embolisation. Twenty seven patients had either grade III or IV splenic injuries. Operative management was more likely in patients with lower haemoglobin or with more severe splenic injury. Nonoperative management can be adopted in patients with blunt isolated splenic injuries but operative management is still indispensable in certain instances.

Triple viral retinitis diagnosed by polymerase chain reaction of the vitreous biopsy in a patient with Richter syndrome.

PURPOSE: To report the evaluation and identification of herpes viruses associated with retinitis in a patient with Richter syndrome. METHODS: Diagnostic vitrectomy was performed on a patient with systemic leukemia and retinitis. The vitreous sample was evaluated by cytology, analysis of cytokines by ELISA, and detection of virus by polymerase chain reaction. RESULTS: The vitreous biopsy specimen showed no malignant cells but predominant CD8+ lymphocyte infiltration with elevated interferon gamma and interleukin-6. DNA amplification and Southern blot analysis demonstrated DNA of herpes simplex, varicella-zoster, and cytomegalovirus. CONCLUSION: Retinitis associated with multiple viruses in the vitreous biopsy may mimic leukemic infiltration in the eye.

Echographic and histologic tumor height measurements in uveal melanoma.

We studied the relation between echographic tumor elevation (measured by standardized A-scan echography) and histologic tumor thickness (measured from histologic slides with an ocular micrometer) in a series of 53 choroidal and ciliary body melanomas enucleated within one month of the most recent echographic measurement. Histologic height was less than echographic height for all sizes and locations studied, with a correlation coefficient of r = .926. The following equations for straight lines described the relationship: Echographic height = 1.964 + (1.042 X histologic height). Histologic height = -0.660 + (0.823 X echographic height). Thus, current thickness criteria for small (less than 3 mm), medium (3 to 5 mm), and large (more than 5 mm) melanomas, based on histologic measurements, may be translated to the following echographic terms: small, less than 5.2 mm; medium, 5.2 to 7.2 mm; and large, more than 7.2 mm. The source of this difference is a variable degree of tumor shrinkage induced by fixation and histologic preparation.

Alvarado score: an admission criterion in patients with right iliac fossa pain.

Appendicitis is an important differential diagnosis in patients with right iliac fossa pain. The diagnosis in patients with equivocal signs can be difficult. Many patients with suspected appendicitis are admitted for observation. We studied the Alvarado scores of 175 patients who presented to the emergency department with right iliac fossa pain and found that patients with scores of 4 or less did not have appendicitis. We also present an algorithm incorporating the Alvarado score for patients with suspected appendicitis.

Clinical features, investigations and pathology in surgically treated thyrotoxicosis.

A retrospective study was conducted on 41 thyrotoxic patients operated from January 1986 to June 1992 in Alexandra Hospital. One had multinodular goitre, and the rest had autoimmune thyroid diseases. Analysis of the histopathological features of the 40 patients with autoimmune thyroid diseases revealed that 32 had Graves' disease, four had Hashimoto's thyroiditis and four had a mixed form of Graves' disease and Hashimoto's thyroiditis. Only 14 out of 32 patients had eye and/or cutaneous manifestation of Graves' disease. None of the patients with Graves' disease developed hypothyroidism over a mean follow-up period of two years post-operatively, whereas one out of four Hashimoto's thyroiditis and two out of the four with the mixed form of Graves' and Hashimoto's thyroiditis had hypothyroidism after surgery. We conclude that it may be difficult to make a diagnosis of Hashimoto's thyroiditis in the early phase when it presents with thyrotoxicosis. Besides, there are cases with a mixed form of both Graves' and Hashimoto's thyroiditis. However, it is important that the diagnosis of Hashimoto's thyroiditis be made before surgery, otherwise progression to hypothyroidism would be accelerated.

Selection of patients for surgery in the management of thyrotoxicosis.

There is at present no consensus as to what the best treatment for thyrotoxicosis is. If the patients are carefully selected, surgery offers a safe and effective cure for the disease over a short period of time. We reviewed the selection criteria of forty-one patients with thyrotoxicosis treated surgically in Alexandra Hospital. Over 90% of the patients were referred for surgery by physicians and general practitioners. The majority (95%) were young patients (under 40 years) and almost all were treated with antithyroid drugs before opting for surgery. The most common indication given for surgery was failure of conservative treatment (20/41). This was followed by patients who had difficulty adhering to the antithyroid drug regime (12/41) and patients who requested surgery for cosmetic reasons (5/41). Almost half of the patients had large glands (> 50g). One year after surgery, 84% of the patients remained euthyroid, 8% developed hypothyroidism and 8% had relapsed thyrotoxicosis. Three quarters of the patients tested positive for thyroid antibodies. This did not appear to increase the rate of hypofunction. There was no mortality from surgery.

Gastrointestinal tract perforation following blunt abdominal trauma: an institution's experience.

PURPOSE: Traumatic perforation of the gastrointestinal tract (GIT) poses numerous challenges for surgeons worldwide. We aimed to review our institution's experience and highlight the pertinent issues in managing this problem. METHODS: A retrospective review was performed for all patients with perforation of the GIT following traumatic blunt injuries. RESULTS: Twenty-one patients, with a median age of 40 years, formed the study group, all of whom underwent surgery. Four patients were sent straight to the operating theater from the emergency department due to hemodynamic instability, while another two patients had pneumoperitoneum on their X-rays. Computed tomography (CT) scan was performed in 15 patients, with the findings of pneumoperitoneum (n = 7, 46.7%) and free fluid without solid organ injury (n = 9, 60.0%) being the most common result. The jejunum (n = 11, 52.4%) and ileum (n = 5, 23.8%) were the most common sites of perforation. Direct repair was performed in 9 (42.9%) patients, while resection of the perforated segment(s) was performed in the remaining 12 (57.1%) patients. Other associated intra-abdominal injuries included mesenteric (n = 6, 28.6%) and splenic lacerations (n = 4, 19.0%). Surgery was performed within 8 h of the accident in only 11 patients (52.4%). Some of the complications included wound infection (n = 7, 33.3%) and intra-abdominal abscesses (n = 3, 14.3%). Two patients underwent relook laparotomy after an initial damage control laparotomy. CONCLUSION: Prompt and early surgery for traumatic gastrointestinal perforation is advised. Any abnormal CT scans warrants either surgery or close monitoring. Direct repair of the perforation is preferred, if possible.

Emergency angio-embolisation in the operating theatre for trauma patients using the C-Arm digital subtraction angiography.

BACKGROUND AND AIMS: Angio-embolisation in trauma is a relatively new technique that is gaining popularity and recognition in identifying and arresting bleeding in trauma patients. We studied the possibility whether angio-embolisation using the Digital Subtraction Angiography (DSA), in the operating theatre (OT) could achieve successful haemostasis in trauma patients. We further studied the feasibility of using this technique as part of trauma resuscitation/damage control. METHODS: A retrospective study of trauma patients, with Injury Severity Score (ISS ≥ 9), admitted to Tan Tock Seng Hospital (TTSH) from January 2004 to December 2008 was done. Patients who had received angio-embolisation in the OT or angiography suite were evaluated in terms of age, gender, ISS, the site and type of angioembolisation used. The primary end point was to assess the success rate of angioembolisation using the C-Arm DSA in the OT, and whether there were any complications necessitating a repeat procedure or surgical intervention. The secondary end points of the study were aimed at studying the cost effectiveness of this technique, logistical feasibility and evaluating this technique as part of the initial trauma resuscitative efforts. RESULTS: A total of 43 trauma patients received angioembolisation. 32 patients had the angio-embolisation done using the C-Arm DSA in the OT (n = 32). None of the patients who received angioembolisation in the operating theatre (n = 32) had any re-bleeding. 15 out of 32 survived. There were no complications related to the angio-embolisation procedure. The majority of angio-embolisations done were for pelvic fractures. CONCLUSION: The success of angio-embolisation in the OT using the C-Arm DSA for a trauma patient and its complication rates are similar to that done in a dedicated angio-graphic suite. We conclude that angio-embolisation in the operating theatre using the C-Arm DSA is feasible, cost effective and can be a modality in the initial trauma resuscitation/damage control in any lead lined operating theatre. We believe that we are the first to describe this method of angio-embolisation using the C-Arm DSA in a conventional lead lined trauma operating theatre and its use as a feasible option in a trauma resuscitation/damage control algorithm.

Chronic pain and its impact on quality of life following a traumatic rib fracture.

PURPOSE: Traumatic rib fractures account for 7-40 % of trauma admissions and most of them heal spontaneously and do not contribute to disability. The prevalence of chronic pain and its impact on quality of life following a traumatic rib fracture has not been studied adequately. METHODS: A retrospective review of electronic medical records of all the traumatic rib fracture admissions from January 2007 to December 2008 was conducted. This was followed up with a brief telephonic survey of the following questions: (1) Do you have pain following the trauma? (2) If YES, how severe is your pain from a score of zero to ten? (3) Does the pain affect your life style? (4) Does the pain affect your work? (5) Do you need to take regular pain medications? RESULTS: One hundred and two patients responded to the survey and 23 patients (22.5 %) complained of chronic persistent pain. In patients with pain, six patients (26 %) had chronic pain that required regular use of analgesics, eight patients (35 %) complained of impairment of work life, and three patients (13 %) complained of impairment of personal quality of life. Chronic pain was not related to age, number of ribs fractured, flail chest, hemothorax and/or pneumothorax, chest tube insertion, or Injury Severity Score (ISS). CONCLUSION: This study confirms the high incidence of chronic pain after a traumatic rib fracture. While the majority of the patients can manage this pain without interference of their quality of life, a few do suffer from life style/work interference and may have to resort to regular analgesic usage.

Management of diaphragmatic rupture from blunt trauma.

INTRODUCTION: Diagnosis of diaphragmatic rupture is difficult, and delays could result in a catastrophic outcome. We reviewed our institution's management of patients with diaphragmatic rupture after blunt trauma. METHODS: All patients in this study were treated at Tan Tock Seng Hospital, Singapore, from March 2002 to October 2008. Patients with penetrating injuries were excluded. The parameters included age, mechanism of injury, haemodynamic status at admission, Glasgow coma scale (GCS) score, injury severity score (ISS), imaging studies, location of diaphragmatic injuries, associated injuries and outcome. RESULTS: 14 patients with a median age of 38 years formed the study group. Vehicular-related incidents accounted for 71.4 percent of the injuries. The median GCS score on admission was 14 (range 3-15), while the median systolic blood pressure and heart rate were 94 (range 50-164) mmHg and 110 (range 76-140) beats per minute, respectively. The median ISS was 41 (range 14-66). All had chest radiographs performed in the emergency department, six (42.9 percent) had computed tomography performed before surgery, while the remaining eight (57.1 percent) were sent straight to the operating theatre from the emergency department. There were five (35.7 percent) right-sided and nine (64.3 percent) left-sided diaphragmatic ruptures. The mortality rate was 35.7 percent. Some of the associated injuries included eight (57.1 percent) splenic lacerations, five (35.7 percent) haemothorax and lung injuries, four (28.6 percent) bone fractures and three (21.4 percent) liver lacerations. 12 (85.7 percent) patients underwent repair of the diaphragmatic rupture using interrupted polypropylene suture, while the remaining two (14.3 percent) were too haemodynamically unstable to undergo definitive treatment. Advanced age, haemodynamic instability and raised ISS were associated with mortality. CONCLUSION: An accurate diagnosis of diaphragmatic rupture in trauma patients is difficult, and a thorough examination of both the hemidiaphragms is mandatory during emergency laparotomy for these patients. Those with more severe injuries and decreased physiological reserves usually fare worse.

Ocular hazard of metallic fragments during MR imaging at 0.06 T.

The hazard of magnetic resonance (MR) imaging at low field strength (0.06 T) was examined by using both in vitro and in vivo animal experiments. Ferromagnetic fragments, 0.25-2.2 mm in diameter, were placed in vitreous humor obtained from excised cow eyes and in rabbit eyes. The magnetic field strength at which motion occurred was measured for each fragment size. Two types of motion, rotation and translation, were observed. The authors found that fragments that could not be seen on plain radiographs did not appear to move enough to be a significant ocular hazard during MR imaging at a field strength of 0.06 T.