Criteria for the selective use of chest computed tomography in blunt trauma patients

Item does not contain fulltextPURPOSE: The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury. METHODS: This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre. RESULTS: We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant. CONCLUSION: Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.1 april 201

Open Appendectomy: No Longer an Intern Case

Laparoscopy and work-hour restrictions are altering surgical training. We hypothesized interns were no longer gaining experience in open appendectomy, historically an intern index case. We retrospectively reviewed Accreditation Council for Graduate Medical Education (ACGME) case logs of postgraduate Year (PGY) 1 general surgery trainees from our academic teaching program for the last 9 years. Number of appendectomies performed (Current Procedural Terminology codes 44950, 44960, and 44970) were recorded and analyzed. The national ACGME database was similarly evaluated for resident experience during junior (PGY-1 to 4) years. Data were available for 47 residents completing internship at our institution between 2003 and 2011. Mean number of appendectomies performed per intern steadily decreased throughout the study period from 22 in 2003 to 5 in 2011 ( P = 0.0367). Mean percentage of cases done open decreased from 79.5 to 2.4 per cent ( P = 0.0001). National data found residents graduating in the year 2000 performed an average of 26.6 open appendectomies during junior years, whereas those graduating in 2011 had done only 13.7. Surgical trainees are performing fewer open appendectomies than just several years ago. Open appendectomy traditionally served as an introduction to open surgery. Because outcome differences are small between open and laparoscopic appendectomy, we propose teaching institutions consider performing open appendectomies in select patients to preserve an important educational experience. </jats:p

Effects of Sorbinil, Dietary <i>myo</i>-Inositol Supplementation, and Insulin on Resolution of Neuroaxonal Dystrophy in Mesenteric Nerves of Streptozocin-Induced Diabetic Rats

Previous studies indicate that experimental diabetic autonomic neuropathy can be largely prevented by initiating therapy at the onset of diabetes. More clinically relevant, however, is the ability of therapy to reverse established neuropathy produced by long-standing diabetes. We have examined the effect of selected therapies on established neuroaxonal dystrophy (NAD) in ileal mesenteric nerves, a rat model of diabetic autonomic neuropathy. Groups of 3-mo-old rats were made diabetic with streptozocin (STZ-D) and allowed to survive untreated for 5 mo, at which time they were begun on sorbinil, dietary myo-inositol, and daily insulin therapies or left untreated for an additional 2 or 4 mo. Ultrastructural evidence of NAD was demonstrated in ileal mesenteric nerves of rats with untreated 5-mo STZ-D and increased with the duration of diabetes. No lesions were demonstrated in control rats of any age. myo-inositol or sorbinil administration failed to alter the severity of diabetes as measured by its metabolic indices. Institution of sorbinil or insulin treatment at 5 mo of diabetes prevented the increase in, but did not normalize, NAD at 7 or 9 mo. Dietary myo-inositol failed to significantly reverse established NAD or prevent its initial development. Morphometric examination of ileal mesenteric nerves demonstrated a decrease in the number of axons comprising each diabetic Schwann cell unit, suggestive of chronic cycles of axonal degeneration and regeneration. This parameter, clearly abnormal by 5 mo of diabetes, was not normalized by 2 or 4 mo of insulin, sorbinil, or myo-inositol treatment. These observations indicate that treatment with insulin or an aldose reductase inhibitor, but not myo-inositol, initiated after the development of structural axonopathy significantly inhibited progression of NAD for the duration of treatment. (ABSTRACT TRUNCATED AT 250 WORDS)</jats:p

Predictors of Mortality in Patients with Penetrating Inferior Vena Cava Injuries Surviving to the Operating Room

Inferior vena cava (IVC) injuries are associated with significant morbidity and mortality. To identify clinical factors associated with mortality in patients undergoing operative intervention for penetrating IVC injuries, a retrospective review of 98 patients was performed, excluding blunt injuries (n = 20) and deaths before surgery (n = 16). The overall mortality was 58 per cent. Nonsurvivors more commonly presented with hypotension (50% vs 23%, P = 0.03) and underwent resuscitative thoracotomy more frequently (42% vs 4%, P = 0.01). Retrohepatic injuries were more common among nonsurvivors ( P = 0.04). There was no difference in the use of ligation (7% vs 17%, P = 0.29) or the massive transfusion protocol (35% vs 25%, P = 0.41). On multivariate analysis, after controlling for mechanism of injury, admission hypotension, Glasgow Coma Scale score, preoperative cumulative fluids, resuscitative thoracotomy, absence of spontaneous tamponade, and location of IVC injury, the only independent predictor of mortality was the absence of spontaneous tamponade at the time of laparotomy (odds ratio = 5.4, 95% confidence interval: 1.11–25.95; P = 0.04). Penetrating IVC injuries continue to be associated with a high mortality, particularly among patients with free intraabdominal hemorrhage at laparotomy. Large multicenter studies are required to define the optimal resuscitative and operative management techniques in these severely injured patients. </jats:p