CT after emergency surgery in penetrating trauma: a seven-year experience in a level I Nordic trauma center.

BACKGROUND: Patients with severe penetrating trauma may require emergency surgery on arrival, and postoperative computed tomography (CT) can reveal significant additional injuries. PURPOSE: To determine the utility of postoperative CT performed within 48 h of emergency surgery after penetrating trauma. MATERIAL AND METHODS: Trauma registry data were retrieved over a seven-year period at a single level 1 trauma center. All patients aged ≥17 years, admitted with penetrating injury, who underwent urgent surgery and postoperative CT imaging within 48 h, were included. Pre- and intraoperative medical records were compared to CT findings. Age, sex, Injury Severity Score (ISS), New Injury Severity Score (NISS), 30-day mortality, injury mechanism, surgical intervention, and intensive care unit length of stay were extracted. RESULTS: Out of 1262 patients, 38 fulfilled the study criteria (36 men [94.7%], 2 women [5.3%]; mean age = 31.5 years. Stab wound (SW) was the most common injury mechanism (26/38, 68.4%) followed by gunshot wound (GSW; 10/38, 26.3%). Patients with GSWs were more severely injured than SW victims (median NISS = 34 [range = 3-75]; for GSWs = 34; for SWs = 26; P = 0.045). Out of 38 patients, 20 (52.6%) had additional findings at postoperative CT. Six patients (15.8%) had unidentified or underestimated findings at CT that were severe enough to warrant additional surgery or angiography. CONCLUSION: Postoperative CT imaging after emergency surgery in penetrating trauma is an important tool in evaluating the injury panorama. Out of 38 patients, 6 (15.8%) had findings at postoperative CT that warranted additional surgical or angiographic intervention.

Diagnostic performance of CT and the use of GI contrast material for detection of hollow viscus injury after penetrating abdominal trauma. Experience from a level 1 Nordic trauma center.

BACKGROUND: Use of gastrointestinal (GI) contrast material for computed tomography (CT) diagnosis of hollow viscus injury (HVI) after penetrating abdominal trauma is still controversial. PURPOSE: To assess the sensitivity of CT and GI contrast material use in detecting HVI after penetrating abdominal trauma. MATERIAL AND METHODS: Retrospective analysis (2013-2016) of patients with penetrating abdominal trauma. Data from the local trauma registry, medical records, and imaging from PACS were reviewed. CT and surgical findings were compared. RESULTS: Of 636 patients with penetrating trauma, 177 (163 men, 14 women) had abdominal trauma (mean age 34 years, age range 16-88 years): 155/177 (85%) were imaged with CT on arrival; 128/155 (83%) were stab wounds and 21/155 (14%) were gunshot wounds; 47/155 (30%) had emergent surgery after CT. Two patients were imaged using oral, rectal and i.v. contrast; 23 with rectal and i.v. contrast; and 22 with i.v. contrast only. Surgery revealed HVI in 26 patients. CT had an overall sensitivity 69.2%, specificity 90.5%, PPV 90.0%, and NPV 70.4%. CT with oral and/or rectal contrast (n = 25) had sensitivity 66.7%, specificity 71.4%, PPV 85.7%, and NPV 45.5%. CT with i.v. contrast only (n = 22) had 75% sensitivity, 100% specificity, PPV 100%, and NPV 87.5%. No statistically significant difference was found between sensitivity of CT with GI contrast material and i.v. contrast only (P = 1). CONCLUSION: Stab wounds were the most common cause of penetrating abdominal trauma. CT had 69.2% sensitivity and 90.5% specificity in detecting HVI. CT with GI contrast had similar sensitivity as CT with i.v. contrast only.

Imaging of penetrating thoracic trauma in a large Nordic trauma center.

BACKGROUND: Penetrating trauma is rarely encountered in Nordic trauma centers, yet the incidence is increasing. Typical imaging findings in penetrating trauma should thus be familiar to all radiologists. PURPOSE: To evaluate incidence and imaging findings of penetrating chest trauma, gunshot wound (GSW) and stab wound (SW) injury spectrum, imaging protocols, and outcome in a large trauma center. MATERIAL AND METHODS: Trauma registry data from 2013-2016 was retrieved, and imaging accessed through hospital PACS. Retrieved variables included age, gender, injury severity scores, mechanism of injury, time to CT, and 30-day mortality. Depth of thoracic, pulmonary, abdominal and skeletal injury, active bleeding, and use of chest tubes were evaluated. RESULTS: Of 636 patients with penetrating injuries, 443 (69.7%) underwent imaging. Of these, 161 (36.3%) had penetrating thoracic injuries. Of 161 patients with penetrating chest trauma in imaging, 151 (93.8%) were men (mean age = 34.9 years) and 10 (6.2%) were women (mean age = 40.7 years). The majority of patients had SWs (138 SW vs. 15 GSW). Patients with GSWs were more severely injured (mean ISS 17.00 vs. 8.84 [P=0.0014] and ISS≥16 in 53.3% vs. 16.7%) than SW patients. In CT, intrathoracic injuries were found in 49.4% (77/156) and active bleeding in 26.3% (41/156). Emergency surgery was performed in 6.2% (10/161) with postoperative CT imaging. Thirty-day mortality rate was 1.2% (2/161). CONCLUSION: Penetrating thoracic trauma often violates intrathoracic structures and nearby compartments. Arterial phase whole-body CT is recommended as multiple injuries and active bleeding are common. CT after emergency surgery is warranted, especially to assess injuries outside the surgical field.

Endovascular recanalization for nonmalignant obstruction of the inferior vena cava.

OBJECTIVE: The aim of this study was to evaluate outcomes of endovascular recanalization of the inferior vena cava (IVC) and iliac veins with long-standing chronic venous obstruction caused by nonmalignant disease. METHODS: Medical records for 66 patients who underwent endovascular recanalization of the IVC with or without iliac veins from January 2001 to December 2014 at our medical center were retrospectively reviewed. Primary outcomes included morbidity and mortality; secondary outcomes included primary, primary assisted, and secondary patency and resolution of symptoms. RESULTS: Forty-five (68%) patients were male; the mean age was 43 years (range, 17-83 years). All but one patient had chronic symptoms (mean duration, 8 ± 9 years). Clinical, Etiology, Anatomy, and Pathophysiology classes included 3, 4a, 4b, 5, and 6 in 41, 2, 1, 2, and 20 patients, respectively. Mean Venous Clinical Severity Score was 12.4 ± 6.5. Fifty-nine patients (89%) had history of deep venous thrombosis, and 13 also had pulmonary embolism. Twenty-five patients (38%) had an IVC filter; 20 (30%) had thrombophilia. The obstruction involved the infrarenal IVC in 44 patients and both the infrarenal and suprarenal IVC in 22 patients. All recanalizations were performed under conscious sedation and local anesthesia and involved sequential angioplasty and stent placement into the IVC, with or without iliac vein stenting. Venous access included bilateral femoral veins and right internal jugular vein. Stents used were Wallstents (Boston Scientific, Marlborough, Mass; n = 70), Protegé stents (ev3, Plymouth, Minn; n = 49), Gianturco (Cook Medical, Bloomington, Ind; n = 44), and Luminexx (Bard, Tempe, Ariz; n = 1). Pressure gradients were 6.7 ± 4.0 mm Hg before and 0.9 ± 1.1 mm Hg after stenting (P < .001). Procedural success was 90% and 100% at first and second attempt at recanalization, respectively. There was no mortality or clinically significant pulmonary embolism. Four patients had five complications: two developed an arteriovenous fistula, one patient developed groin hematoma that required open evacuation, and one had peri-IVC hematoma and femoral vein thrombosis that required repeated angioplasty and stenting; 93% of patients received long-term anticoagulation. Follow-up was 42 ± 36 months. Four patients were lost to follow-up. Primary patency, primary assisted patency, and secondary patency at 36 months were 78%, 87%, and 91%, respectively. Symptoms resolved in 83% of patients. On multivariable regression analysis, hypercoagulable state was the only predictor of reocclusion of the recanalized veins. CONCLUSIONS: Endovascular recanalization for nonmalignant symptomatic IVC and associated iliofemoral venous obstruction with balloon angioplasty and self-expanding stents is technically challenging; however, it is safe and durable. In our retrospective study, estimated patency rates at 36 months were >85%, and clinical outcomes were excellent. Venous stenting should be attempted for chronic nonmalignant IVC and associated iliac or iliofemoral venous obstructions before open surgical reconstruction is contemplated.

Increasing incidence of late-onset neonatal invasive group B streptococcal infections in Iceland.

BACKGROUND: Group B streptococci (GBS) may cause life-threatening invasive infections in infants. The incidence of these infections has been increasing during the last decades. The aim of the study was to determine the epidemiology of neonatal GBS infections to be able to implement therapeutic and preventive measures more effectively. METHODS: A retrospective case study was conducted in Iceland that included all neonates with positive GBS cultures from blood or cerebrospinal fluid during the period 1975 to 2006. Serotyping of all available GBS isolates was performed. RESULTS: A total of 87 children with 89 infections were included in the study. In all, 53 infants had early-onset (EO) GBS infections (occurring <7 days after birth) and 34 had late-onset (LO) infections (occurring on days 7-90). EO infections increased during the first 3 quartiles of the study period but decreased during the last quartile. LO infections increased throughout the entire study period. GBS was cultured from cerebrospinal fluid in 21 patients; 9 with EO and 12 with LO infections. Premature infants comprised 15 with EO and 14 with LO infections. Eight children died of GBS infection, 7 with EO and 1 with LO infections; no correlation with serotypes was found. Serotype III was most common for both EO (34%) and LO infections (62%). CONCLUSION: The number of GBS infections increased during the study period. The decrease in EO infections in recent years could be attributed to intrapartum antibiotic treatment. The increasing number of LO infections is a concern.