Immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures: is it safe enough?

OBJECTIVES: The purpose of this study was to compare the results of immediate and delayed percutaneous sacroiliac screws surgery for unstable pelvic fractures, regarding technical results and complication rate. DESIGN: Retrospective study. SETTING: The study was conducted at the Soroka University Medical center, Beer Sheva, Israel, which is a level 1 trauma Center. PATIENTS: 108 patients with unstable pelvic injuries were operated by the orthopedic department at the Soroka University Medical Center between the years 1999-2010. A retrospective analysis found 50 patients with immediate surgery and 58 patients with delayed surgery. Preoperative and postoperative imaging were analyzed and data was collected regarding complications. INTERVENTION: All patients were operated on by using the same technique-percutaneous fixation of sacroiliac joint with cannulated screws. MAIN OUTCOME MEASUREMENTS: The study's primary outcome measure was the safety and quality of the early operation in comparison with the late operation. RESULTS: A total of 156 sacroiliac screws were inserted. No differences were found between the immediate and delayed treatment groups regarding technical outcome measures (P value = 0.44) and complication rate (P value = 0.42). CONCLUSIONS: The current study demonstrated that immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures produced equally good technical results, in comparison with the conventional delayed operation, without additional complications.

Tyrphostin AG 556 improves survival and reduces multiorgan failure in canine Escherichia coli peritonitis.

Tyrosine kinase-dependent cell signaling is postulated to be a pivotal control point in inflammatory responses initiated by bacterial products and TNF. Using a canine model of gram-negative septic shock, we investigated the effect of tyrosine kinase inhibitors (tyrphostins) on survival. Animals were infected intraperitoneally with Escherichia coli 0111: B4, and then, in a randomized, blinded fashion, were treated immediately with one of two tyrphostins, AG 556 (n = 40) or AG 126 (n = 10), or with control (n = 50), and followed for 28 d or until death. All animals received supplemental oxygen, fluids, and antibiotics. Tyrphostin AG 556 improved survival times when compared to controls (P = 0.05). During the first 48 h after infection, AG 556 also improved mean arterial pressure, left ventricular ejection fraction, cardiac output, oxygen delivery, and alveolar-arterial oxygen gradient compared to controls (all P < or = 0.05). These improvements in organ injury were significantly predictive of survival. Treatment with AG 556 had no effect on clearance of endotoxin or bacteria from the blood (both P = NS); however, AG 556 did significantly lower serum TNF levels (P = 0.03). These data are consistent with the conclusion that AG 556 prevented cytokine-induced multiorgan failure and death during septic shock by inhibiting cell-signaling pathways without impairing host defenses as determined by clearance of bacteria and endotoxin.

Abeta induces cell death by direct interaction with its cognate extracellular domain on APP (APP 597-624).

Amyloid beta-peptide (Abeta) is postulated to play a central role in the pathogenesis of Alzheimer's disease. We recently proposed a pathway of Abeta-induced toxicity that is APP dependent and involves the facilitation of APP complex formation by Abeta. The APP-dependent component requires cleavage of APP at position 664 in the cytoplasmic domain, presumably by caspases or caspase-like proteases, with release of a potentially cytotoxic C31 peptide. In this study we show that Abeta interacted directly and specifically with membrane-bound APP to facilitate APP homo-oligomerization. Using chimeric APP molecules, this interaction was shown to take place between Abeta and its homologous sequence on APP. Consistent with this finding, we demonstrated that Abeta also facilitated the oligomerization of beta-secretase cleaved APP C-terminal fragment (C99). We found that the YENPTY domain in the APP cytoplasmic tail and contained within C31 is critical for this cell death pathway. Deletion or alanine- scanning mutagenesis through this domain significantly attenuated cell death apparently without affecting either APP dimerization or cleavage at position 664. This indicated that sequences within C31 are required after its release from APP. As the YENPTY domain has been shown to interact with a number of cytosolic adaptor molecules, it is possible that the interaction of APP, especially dimeric forms of APP, with these molecules contribute to cell death.

Adenosine in burn blister fluid.

BACKGROUND: Burn wound blister fluid is known to sustain suppressive effects on various components of the immune system. Damaged tissues cause an increase of adenosine concentrations. Since adenosine is a potent anti-inflammatory agent we hypothesized that burn blister fluid contains high concentrations of this nucleoside. METHODS: Burn blister fluid was drawn from eleven patients who suffered a second degree burn injury. Adenosine concentrations were determined using high performance liquid chromatography (HPLC). RESULTS: Elevated adenosine levels were detected in 6 of the 11 patients (54.5%), with an overall mean of 1.13+/-0.52 mM. CONCLUSIONS: This is the first documented data showing increased concentrations of adenosine in burn blister fluid.

The contribution of the Israeli trauma system to the survival of road traffic casualties.

BACKGROUND: According to the World Health Organization, over one million people die annually from traffic crashes, in which over half are pedestrians, bicycle riders and two-wheel motor vehicles. In Israel, during the last decade, mortality from traffic crashes has decreased from 636 in 1998 to 288 in 2011. Professionals attribute the decrease in mortality to enforcement, improved infrastructure and roads and behavioral changes among road users, while no credit is given to the trauma system. Trauma systems which care for severe and critical casualties improve the injury outcomes and reduce mortality among road casualties. GOALS: 1) To evaluate the contribution of the Israeli Health System, especially the trauma system, on the reduction in mortality among traffic casualties. 2) To evaluate the chance of survival among hospitalized traffic casualties, according to age, gender, injury severity and type of road user. METHODS: A retrospective study based on the National Trauma Registry, 1998-2011, including hospitalization data from eight hospitals. OUTCOMES: During the study period, the Trauma Registry included 262,947 hospitalized trauma patients, of which 25.3% were due to a road accident. During the study period, a 25% reduction in traffic related mortality was reported, from 3.6% in 1998 to 2.7% in 2011. Among severe and critical (ISS 16+) casualties the reduction in mortality rates was even more significant, 41%; from 18.6% in 1998 to 11.0% in 2011. Among severe and critical pedestrian injuries, a 44% decrease was reported (from 29.1% in 1998 to 16.2% in 2011) and a 65% reduction among bicycle injuries. During the study period, the risk of mortality decreased by over 50% from 1998 to 2011 (OR 0.44 95% 0.33-0.59. In addition, a simulation was conducted to determine the impact of the trauma system on mortality of hospitalized road casualties. Presuming that the mortality rate remained constant at 18.6% and without any improvement in the trauma system, in 2011 there would have been 182 in-hospital deaths compared to the actual 108 traffic related deaths. A 41% difference was noted between the actual number of deaths and the expected number. CONCLUSIONS: This study clearly shows that without any improvement in the health system, specifically the trauma system, the number of traffic deaths would be considerably greater. Although the health system has a significant contribution on reducing mortality, it does not receive the appropriate acknowledgment or resources for its proportion in the fight against traffic accidents.

[Ectopic pancreas in the gastric wall with massive bleeding].

A 30-year-old man was admitted because of fatigue, vertigo and 2 episodes of melena. Endoscopy showed a tumor in the gastric antrum which appeared benign, as was also its appearance on barium meal. The source of the bleeding was the mucosa overlying the tumor. Antrectomy was performed with Billroth I anastomosis. Histopathological examination revealed the tumor to be an ectopic pancreas in the gastric wall.

[Management of pancreatic trauma in damage-control laparotomy].

Major pancreatic trauma challenges the trauma surgeon with diagnostic problems and choices of treatment modalities. The most important determinant guiding management is the integrity of the main pancreatic duct. The preoperative and intraoperative assessment and treatment of pancreatic injury may be difficult, especially when concurrent severe injuries are present. There are alternative approaches in the management of the traumatized pancreas when ductal injury is not obvious during initial exploratory laparotomy.

[Management of penetrating cardiac injuries].

Penetrating cardiac injury is often fatal. Patients present with a variety of clinical patterns, from a stable patient but with an insidious course, to those admitted with waning vital signs. In all cases prompt diagnosis and treatment are crucial. A series of 98 cases is presented, emphasizing the problems in diagnosing this condition and recommending the way such patients should be triaged and treated.

[Traumatic rupture of the diaphragm in an infant].

Traumatic rupture of the diaphragm can be caused by both penetrating and blunt trauma. High kinetic energy applied to the abdomen during blunt abdominal trauma creates pressure differences between the abdominal and chest cavities. These sudden changes in pressure rupture the diaphragm. We present a 13-month-old infant admitted after being injured by a car. In addition to rupture of the diaphragm there were pelvic fractures. Chest x-ray on admission was diagnostic for diaphragmatic rupture. The possibility of congenital diaphragmatic hernia was rejected because of increasing ventilatory embarrassment.

[Retroperitoneal perforation after endoscopic sphincterotomy: the dilemma of management].

Retroperitoneal perforation is an occasional complication of endoscopic retrograde cholangiopancreatography, which is expected to increase in frequency. The outlook for patients with this complication is good. Conservative, nonsurgical management is suitable for most patients. The main goal is to achieve adequate drainage of the common bile duct which can be done endoscopically. Despite persistent obstruction an initial period of conservative management is usually appropriate. Surgical intervention should be withheld until the patient's condition is becoming worse, or until a complication such as localized retroperitoneal abscess is recognized.

[Traumatic aortocaval fistula].

Arterio-venous fistula is a relatively rare form of vascular injury. A case of an unusual fistula between aorta and inferior vena cava is presented. Occasionally this type of injury is difficult to diagnose early. Life-threatening conditions may mandate prompt treatment and the use of damage control strategy. It is also important to diagnose and treat this injury in order to prevent complications. Sudden hemorrhage and congestive heart failure are the major disturbances that result from aortocaval fistula.

[Experience with laparoscopic appendectomy].

During April to August 1992, laparoscopies were performed in this department in 35 of 100 cases of appendicitis. The average patient age was 29 years; 18 of the 35 (51%) were women; 3 patients were operated on electively, and the rest as emergencies. Appendectomy was performed in 33 (94%), but not in 2 women with sepsis due to tubo-ovarian abscess; In 1 of these 2 we had to convert to laparotomy. Acute appendicitis was found in 20 (57%). In 7 women (20%) gynecologic disease was diagnosed. In 1 case (3%) a carcinoid tumor of the tip of the appendix was found and in another primary peritonitis. In the remaining 6 (17%) no lesions were found. In 33 (94%) a regular diet was resumed 25 hours postoperatively and 25 (71%) were discharged the day after operation. The only complication was an abdominal wall hematoma in a single case, which resolved spontaneously. It is our impression that laparoscopy is a useful diagnostic tool in acute appendicitis, that it is a safe route for appendectomy, and that recovery is quick with minimal complications.

[Acute ischemia of the lesser gastric curvature--a rare marker of sclerotic disease].

The rich blood supply of the stomach protects it from ischemia and necrosis. Acute gastric ischemia, an emergency with high mortality, is rare. Atherosclerosis is the leading cause of acute ischemia, and the lesser curvature of the stomach is more vulnerable due to its relatively lesser blood supply. Reduction in gastric blood supply usually presents as chronic disease characterized by gastritis, gastric ulcer, or gastroparesis. Gastroscopy can identify lesions of the gastric mucosa, and angiography demonstrates occluded vessels. Treatment of acute gastric ischemia is surgical, with total gastrectomy preferred over partial resection.

[Selective embolization of hepatic arteries--an additional precaution to control hemorrhage in the management of severe liver trauma].

Two cases of severe hepatic injury in which selective hepatic artery embolization was used to control hemorrhage are presented. The first case is that of a 35 year old patient who sustained a severe liver injury after a car accident. A CAT scan of the abdomen revealed an AAST grade 5 liver injury, pooling of contrast material within the liver parenchyma, and blood within the peritoneal cavity. The patient was given fluid resuscitation and taken to angiography where bleeding from branches of the right hepatic artery was demonstrated. While angiography was being undertaken the hemodynamic status of the patient deteriorated, blood transfusion was started, and a selective embolization of the right hepatic artery was performed. The bleeding stopped promptly and hemodynamic stability was regained. The second case is that of a 40 year old pedestrian run over by a car. Abdominal ultrasound revealed free fluid in the peritoneal cavity and the patient was rushed to the O.R. Crushed right lobe of the liver, and inferior vena cava and bowel tears were found. After perihepatic packing and resection of the right and sigmoid colons retrohepatic vena cava tear was repaired and perihepatic packing restored. The abdominal cavity was closed and the patient was taken to the ICU for the correction of hypothermia, metabolic acidosis, and coagulopathy that had developed during the surgery. After 8 hours in the ICU the patient was transferred for angiography and a selective embolization of branches of the right hepatic artery was performed. The clinical course of the patients after angiographic embolization of the hepatic arteries is described and the literature that discusses the use of angiography and embolization of hepatic arteries after traumatic hepatic bleeding is reviewed.

Civilian injuries due to unexploded ordnance in military training areas in southern Israel.

BACKGROUND: The problem of unexploded ordnance (UXO) is global and is usually associated with active or former war zones. Civilian injuries due to UXO in military training areas are not common. METHODS: This is a retrospective case series study based on prospectively collected data on patients who sustained injuries from UXO explosions and were admitted to the Soroka University Trauma Center during a five-year period. RESULTS: Twelve patients were included in this series. All patients were Bedouin and the distribution of injuries was concentrated around the head and upper and lower extremities, with sparing of the torso. CONCLUSION: Awareness and implementation of preventive measures are expected to reduce the incidence of this type of injury.

Laparoscopic cholecystectomy for empyema of gallbladder during pregnancy.

Laparoscopic cholecystectomy has gained great popularity during the last few years. This procedure has advantages over the traditional open operation, thus making it the standard method for removal of the gallbladder at present. Only a few cases of laparoscopic cholecystectomy during pregnancy have been reported. On the other hand, some authors classify pregnancy as one of the contraindications for this procedure.

Superoxide production by neutrophils from trauma patients: regulation of NADPH oxidase activity.

The production of free oxygen radicals by polymorphonuclear cells (PMNs) was studied in 25 patients after blunt trauma. Superoxide generation significantly increased immediately after trauma and returned to normal soon after the event. Patients were subsequently divided into two groups: those who developed sepsis and those who did not develop infectious complications. Superoxide production by intact PMNs following stimulation by three different stimulants was initially not different in trauma patients who developed sepsis. Follow-up showed an increase in superoxide production when infection complicated the course of trauma patients. Further studies were performed in a cell-free system containing cell membranes and cytosol from patients or healthy controls. No difference in the production of superoxide was found when membranes from trauma patients or controls were mixed with cytosols from controls. When cytosols from patients were mixed with membranes from controls, a significant increase in superoxide production was observed in the group that developed sepsis. Immunoblotting analysis of two protein components of the cytosolic portion of the NADPH oxidase, p47 and p67, were done. The increase in quantity of p47 correlated with the increase in superoxide production during sepsis, and thus may be the major contributor to the high activity.

A protease-resistant prion protein isoform is present in urine of animals and humans affected with prion diseases.

Prion protein (PrP)(Sc), the only known component of the prion, is present mostly in the brains of animals and humans affected with prion diseases. We now show that a protease-resistant PrP isoform can also be detected in the urine of hamsters, cattle, and humans suffering from transmissible spongiform encephalopathies. Most important, this PrP isoform (UPrP(Sc)) was also found in the urine of hamsters inoculated with prions long before the appearance of clinical signs. Interestingly, intracerebrally inoculation of hamsters with UPrP(Sc) did not cause clinical signs of prion disease even after 270 days, suggesting it differs in its pathogenic properties from brain PrP(Sc). We propose that the detection of UPrP(Sc) can be used to diagnose humans and animals incubating prion diseases, as well as to increase our understanding on the metabolism of PrP(Sc) in vivo.

Gastric outlet obstruction by gallstone: Bouveret syndrome.

Gallstone has rarely been described as a cause of gastrointestinal obstruction. However, the relative incidence of gallstone ileus increases significantly with age. The gastric outlet is very seldom the location of obstruction by a gallstone. The diagnosis of this condition is not difficult. Nevertheless, if treatment is delayed, high morbidity and mortality rates result. Comprehensive treatment aims to relieve the obstruction, to close the biliodigestive fistula and to prevent further gallbladder complications. The surgeon who deals with this type of illness should tailor the treatment plan according to the age, general condition, and intraoperative findings of the individual patient. This paper presents a case report of an 88-year-old woman with gastric outlet obstruction caused by a gallstone.

Acute acalculous cholecystitis--experimental and clinical observations.

Induction of acute acalculous cholecystitis was studied in dogs. Designed models included ligation of the cystic artery and/or duct separately or combined and injection of colonic flora into the gallbladder. Cholecystectomy was performed 72 h later. Histological studies of the gallbladders and bile cultures demonstrated various degrees of cholecystitis, the severest form occurring as a result of cystic artery ligation, whereas the mildest was produced by injection of bacteria. Secondary infection was a constant feature of our experimental models.