The role of computed tomography in determining delayed intervention for gunshot wounds through the liver.

INTRODUCTION: Gunshot wounds through the liver are highly lethal and are prone to delayed morbidity due to late complications. METHODS: A retrospective study was performed to determine the incidence, morbidity, and need for late interventions in patients shot through the liver, and the role of post-injury CT in making those determinations. RESULTS: 83 patients were shot through the liver. Injury grades were: Grade V-12 (14 %), Grade IV-41 (49 %), Grade III-12 (14 %), Grade II-8 (10 %), Grade I-1 (1 %), and nine were ungraded. Ten (12 %) died in the ED, three (4 %) died in the OR, and two (2 %) died postoperatively. Of the 68 survivors, 52 (76 %) had follow-up CT scans performed a median of 7 days (95 % CI 2-13 days) after injury. Seventeen (33 %) had 25 complications related to the bullet tract: 12 (48 %) abscesses, 6 (24 %) infected hematomas, 3 (12 %) bilomas, 3 (12 %) unclassified fluid collections, and 1 (4 %) hepatic necrosis. Treatment included CT-guided drainage in 15 (60 %), ultrasound-guided drainage in 3 (12 %), surgical drainage and debridement in 2 (8 %), and observation in 5 (20 %). Overall morbidity rate including hepatic and non-hepatic complications was 74 % (50/68). Patients having their CT scan-determined intervention (for all complications) within 7 days of injury (n = 24), compared to those having their CT scan-determined intervention on day 8 or later (n = 28), had a significantly decreased rate of overall complications and morbidity (p = 0.03). This difference was due to early detection and intervention for abscesses, anastomotic breakdown, and missed injuries. Those having a CT scan within 7 days of injury also had a significantly reduced length of stay compared to those scanned on day 8 or later (median 14 days, 95 % CI 4-24 days versus 18 days, 95 % CI 6-30 days, p = 0.05). CONCLUSIONS: Gunshot wounds to the liver have a high morbidity and mortality rate. Survivors should have a follow-up CT scan performed within 7 days to allow detection and intervention for complications, as this dramatically decreases the overall morbidity rate and length of stay.

Trend of human brucellosis over a decade at tertiary care centre in North Karnataka.

BACKGROUND: Brucellosis is an important zoonotic disease. India having a major agrarian population is expected to have a higher prevalence. However, due to lack of laboratory facility or awareness among clinicians, the disease is largely underreported. The aim of this study was to know the prevalence and trend of human brucellosis over a decade, in patients attending a teaching hospital in North Karnataka, and to understand their geographical distribution. MATERIALS AND METHODS: The study was conducted from January 2006 to December 2015 at a tertiary care teaching hospital in North Karnataka. A total of 3610 serum samples were evaluated from suspected cases of brucellosis. All serum samples were initially screened by Rose Bengal plate test, and positive samples were further analysed by Serum agglutination test (SAT) using standard Brucella abortus antigen from Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India. A titre above or equal to 1:80 IU/ml was considered as positive. Demographic data such as age, sex and native place of these patients were also analysed. RESULTS: We observed that human brucellosis is present in North Karnataka. The overall seropositivity of brucellosis in suspected cases was 5.1%. The positive titres ranged from 1:80 to 163,840 IU/ml. The majority of the patients were from Gadag, Koppal and Haveri districts of North Karnataka. CONCLUSION: Our study confirms the presence of human brucellosis in the northern part of Karnataka. Further studies to understand the prevalence of animal brucellosis in these areas will help in implementing prevention measures.

Treatment of massive acute pulmonary embolism. The use of low doses of intrapulmonary arterial streptokinase combined with full doses of systemic heparin.

The efficacy of low-dose, locally administered streptokinase (SK) combined with full therapeutic systemic doses of heparin was investigated. Seven patients with angiographically proven massive acute pulmonary embolism were treated. Streptokinase, 10,000-20,000 units/hour, was administered directly into the left or right pulmonary artery for 9 to 24 hours. Heparin was administered concurrently. The number of unperfused segments of the infused lung shown on the lung scan decreased from 5 +/- 2 to 2 +/- 1 after 12-24 hours (p less than .01). No change was shown in the contralateral lung. The angiographic index of severity score in the infused lung decreased from 16 +/- 1 to 9 +/- 4 (p less than .01). The partial pressure of oxygen in arterial blood improved within four hours. In spite of the low doses of streptokinase, however, two major bleeding episodes occurred that required blood transfusion. In conclusion, low dose intrapulmonary streptokinase, combined with intravenous heparin, may provide a therapeutic option in patients with life-threatening massive acute pulmonary embolism in whom full dose lytic therapy may be hazardous, although even low dose lytic therapy was associated with risk.

Massive hemoptysis: control by transcatheter bronchial artery embolization.

Massive hemoptysis (600 ml in 48 hours) has an ominous prognosis with a mortality of 50 to 100% in medically treated patients and up to 35% in patients undergoing operation. Surgical resection has been the procedure of choice in patients with massive hemoptysis. Those with a contraindication to operation present a particularly frustrating problem. We have treated 7 such patients with massive hemoptysis by transcatheter bronchial artery embolization. In all 7, the bleeding was arrested. Two patients died of recurrent hemoptysis, 1 ten days and the other 2 months following embolization, and 5 are well 1 month to one year later. Transcatheter bronchial artery embolization is a valuable therapeutic modality in patients with massive hemoptysis. However, the procedure is palliative, and, therefore, elective resection must be considered as definitive treatment in those patients who have no contraindication to operation.

Chronic renal failure secondary to post-hysterectomy vaginal prolapse.

The first case of posthysterectomy vaginal prolapse and associated chronic renal failure requiring hemodialysis is presented. A review of the literature on vaginal prolapse and the mechanism and physiology of chronic renal obstruction in this setting is reviewed.

Lung torsion: preoperative diagnosis with angiography and computed tomography.

In a patient with lung torsion, computed tomography demonstrated an occluded right upper lobe bronchus with opacified posterior lung. A pulmonary angiogram demonstrated the right upper lobe artery to be posteriorly and inferiorly displaced into the consolidated lung. In selected cases, computed tomography and angiography can help to confirm a torsed lung.

Successful embolization of multiple AV foot lesions--a case history.

A 39-year-old white female with multiple arteriovenous malformations of the left foot had had surgical ligation on her left dorsalis pedis artery at age 12 with no clinical improvement. She was placed into a leotard at age 16 and was able to function but would tire very easily and her left foot was twice the size of her right one. In May 1988, she had four large feeder vessels off the posterior tibial artery and two off the anterior tibial artery embolized by use of 1,000 microns PVA particles, occlusive spring coils, and detachable balloons. Her foot shrunk and is now smaller than her normal right foot; she does not tire, and she now wears a knee length stocking to help prevent other channels from opening.

Separation of a ruptured angioplasty balloon with successful percutaneous retrieval--a case report.

A case of ruptured angioplasty balloon with complete separation from the catheter is presented. Successful percutaneous retrieval of the balloon with endoscopic biopsy forceps was performed.

Isolated pulmonary artery stenosis: four-year follow-up: case report.

The authors present a four-year follow-up of a patient with a single isolated right main pulmonary artery stenosis without an associated cardiac anomaly. This is an extremely uncommon lesion thought to be congenital. This case illustrates the stability of isolated lesions of the pulmonary vasculature without associated cardiac defects.

Portal hypertension workup by DSA.

To provide information for preoperative planning, combined, selective intravenous (IV) and intraarterial (IA) digital subtraction angiography (DSA) studies were performed on 42 portal hypertension patients scheduled for portal systemic shunt procedures. Selective IV-DSA was performed to demonstrate the hepatic venous system, left renal vein, and inferior vena cava. Portal venous anatomy, direction of flow, and portal systemic collaterals were evaluated by selective IA-DSA. In addition, selective IA-DSA was performed postoperatively on 8 patients to assess shunt patency. Technically adequate DSA studies, suitable for surgical planning or postoperative assessment, were obtained in all of the 50 patients examined. Patient or internal organ motion was not a limiting factor in any study. Such use of DSA represents an efficacious, safe, and cost-effective alternative to conventional film-screen angiography for the evaluation of patients with portal hypertension.

Emergency department repair of hand lacerations using absorbable vicryl sutures.

The use of absorbable suture material has a number of potential advantages when compared to nonabsorbable suture. We conducted a 5-year retrospective study of 102 patients with hand lacerations and compared the quality of scar formation and healing in these patients. Those patients who did not have tendon, nerve, or bone injury were included in the study. Lacerations were repaired with either 5-0 Vicryl or nylon. There were no reported complications or infections in any study group patient. The quality of scar, when compared visually and by palpation, was the same at the end of 6 months. In addition, there was no difference in the incidence of scar retraction. We conclude that the use of absorbable suture material is an acceptable alternative in the repair of hand lacerations.

Transverse bayonet dislocation of the distal interphalangeal joint--a case report.

Transverse bayonet dislocation of an interphalangeal joint is an unstable injury caused by the disruption of both collateral ligaments. This injury pattern in proximal interphalangeal joint was first described by Patel et al. (Clin Orthop Rel Res. 1978;133:219), who coined the term "bayonet dislocation" to describe this particular type of injury. The case of a distal interphalangeal transverse dislocation is presented. This dislocation was successfully treated by closed reduction and immobilization with an aluminum splint and buddy taping to the adjacent finger.

Abnormal pelvic venous collaterals demonstrated during a gastrointestinal bleeding study.

A Tc-99m blood cell study, performed on a patient with suspected gastrointestinal bleeding, demonstrated an unusual configuration of pelvic venous collaterals associated with idiopathic iliac vein occlusion. The cause of these findings subsequently was confirmed by intravenous digital subtraction angiography. This case demonstrates the importance of the dynamic phase of gastrointestinal bleeding studies in correctly identifying vascular abnormalities.

Association of platelet count and serological markers of dengue infection- importance of NS1 antigen.

INTRODUCTION: Dengue is an acute viral infection with potential fatal complications. Specific antibody detection has been the mainstay of diagnosis which is prone for both false positive and false negative reactions. The newer parameter NS1 appears to be highly specific and reliable for diagnosis of dengue infection from the first day of fever. Platelet count is the only accessory test for diagnosis of dengue infection in the peripheral laboratories. Therefore, we tried to evaluate the association of platelet counts against NS1 and IgM/IgG in dengue infections. MATERIALS AND METHODS: Serum samples from clinically suspected dengue cases were tested for NS1, IgM and IgG by immunochromatography-based test. Platelet counts were obtained for all positive cases and 150 dengue seronegative cases of fever that served as controls. Test results of dengue-specific parameters were compared against platelet counts. The proportions obtained were compared by Standard error of the difference between the proportions (SEP test). RESULTS: Of 2104 samples tested, 320 were positive for one or more dengue parameters. Of the 320, 95 were positive for NS1 only, 161 showed IgM only while 9 showed IgG only. More than one marker was detected in the remaining 55 samples. Thrombocytopenia was more consistently associated whenever NS1 was detected compared to antibody detection (P value <0.001). CONCLUSIONS: Inclusion of NS1 in the diagnosis of dengue increases the detection rate significantly. In cases of fever, thrombocytopenia is more consistently found in dengue positive rather than dengue negative subjects. It correlates well when NS1 and IgM are detected simultaneously.

Surgical treatment of carotid paragangliomas presenting unusual technical difficulties. The value of preoperative embolization.

Although the application of reconstructive vascular surgical procedures to the treatment of carotid paragangliomas has made their resection the method of choice and has produced excellent cure rates, it has not obviated some of the technical problems presented by excessively vascular, adherent, or bulky lesions. Our experience with preoperative trans-catheter embolization for the reduction of the vascularity in six cases of this group of lesions is presented and the conclusion is made that preoperative embolization greatly reduced operative technical difficulties.

Evaluation of intravascular low-osmolality contrast agents.

The chemistry of low-osmolality contrast agents is reviewed, the effects of these agents on vascular and organ physiology are compared with the effects of conventional ionic contrast media, and guidelines for intravascular use of the low-osmolality agents in selected high-risk patients are presented. Three low-osmolality contrast agents, the nonionic media iohexol (Omnipaque, Winthrop-Breon) and iopamidol (Isovue, Squibb) and the dimeric medium ioxaglate meglumine-sodium (Hexabrix, Mallinckrodt) have recently been introduced into the contrast-media market. Compared with conventional ionic contrast media, these new agents demonstrate approximately one third of the osmolality per given iodine concentration (degree of roentgenographic opacification). Therefore, the risks of hyperosmolarity-induced reactions to contrast media are lower with the new agents. The low-osmolality agents may be associated with a reduced incidence of contrast-media-induced hypersensitivity reactions. Because of their lower osmolality, these agents produce less vessel dilation, vascular endothelial damage, and associated pain and discomfort than equi-iodine concentrations of the conventional ionic media. They also demonstrate a reduction in the incidence and severity of contrast-media-induced renal vasoconstriction and proteinuria, hemodynamic alterations, negative chronotropic effects, depression of myocardial contractility, and neurotoxicity in the presence of an altered blood-brain barrier. These low-osmolality agents produce fewer undesirable physiological effects than conventional contrast agents, but the cost of the new products can be more than 10 times as great. Therefore, the new products should be used selectively in patients known to be at increased risk for reactions to intravascular contrast media. A scoring system was developed to permit rapid recognition of documented single or multiple risk factors and subsequent determination of whether to administer a low-osmolality agent.

Balloon dilation of the femoral vein expediting percutaneous Greenfield vena caval filter placement.

A balloon angioplasty catheter was used to dilate the femoral vein puncture site before placement of a Greenfield vena caval filter in nine patients. Compared with the conventional use of serial coaxial dilators, this technique expedites filter placement with minimal trauma and bleeding at the puncture site.

Superior vena cava obstruction: evaluation with digital subtraction angiography.

Superior vena cava (SVC) obstruction is an uncommon but dramatic clinical presentation that often requires immediate treatment. We present a technique for evaluation of SVC syndrome using small-gauge butterfly needles and intravenous digital subtraction angiography, and we report our results in ten patients. We find this technique superior to conventional venography since it is rapid, easy, safe, and more cost-effective to perform.

Mycotic aneurysms in intravenous drug abusers: the utility of intravenous digital subtraction angiography.

Two-hundred thirteen intravenous digital subtraction angiographic (DSA) examinations were performed on 195 intravenous drug abusers to rule out the possibility of a mycotic aneurysm in a groin, neck, or upper extremity infection. Twenty-three surgically proved cases of mycotic aneurysm were correctly identified with no false positive results. In addition, six cases of major venous occlusion were documented. We present the results of our experience and conclude that DSA is an effective and cost-efficient method of examining this high risk patient population.

Acute lower gastrointestinal hemorrhage: treatment by superselective embolization with polyvinyl alcohol particles.

OBJECTIVE: The major risk of transcatheter embolotherapy for acute hemorrhage in the lower gastrointestinal tract is irreversible intestinal ischemia. The authors studied the efficacy and safety of superselective transcatheter embolization with polyvinyl alcohol particles in arresting acute hemorrhage in the lower gastrointestinal tract. SUBJECTS AND METHODS: All patients with clinical or scintigraphic evidence of acute hemorrhage in the lower gastrointestinal tract were considered for superselective embolization. The nine patients with angiograms that showed active hemorrhage in the lower gastrointestinal tract underwent the procedure. Superselective embolization was done through a 3-French catheter and was accomplished by using 100- to 590-microns polyvinyl alcohol particles. The segments of the intestinal tracts involved in the embolizations were examined for the presence of ischemia by endoscopy (n = 7) or histologic evaluation of a surgical specimen (n = 2) 2-44 days (mean, 11 days) after embolization or by clinical evaluation (n = 1). RESULTS: The lesions treated by this method were located in the colon (n = 8) and jejunum (n = 1). Immediate hemostasis was achieved in every case. Three patients had recurrent lower gastrointestinal hemorrhage 1-24 days (mean, 9 days) after initial embolization. Two of these patients had surgery, while one had a successful second embolization. Two asymptomatic patients were found endoscopically to have small areas of ischemia involving only the mucosa. Only one patient was shown to have severe mucosal ischemia; this involved the colon in a distribution that suggested it was not caused by the embolization. CONCLUSION: Ten superselective embolization procedures that used polyvinyl alcohol particles successfully controlled hemorrhage in the lower gastrointestinal tract in nine patients. In no case was intestinal infarction induced by the procedure, and only two endoscopically proved cases of asymptomatic mucosal ischemia occurred.