Acute appendicitis: prospective evaluation of a diagnostic algorithm integrating ultrasound and low-dose CT to reduce the need of standard CT

Objectives: To evaluate an algorithm integrating ultrasound and low-dose unenhanced CT with oral contrast medium (LDCT) in the assessment of acute appendicitis, to reduce the need of conventional CT. Methods: Ultrasound was performed upon admission in 183 consecutive adult patients (111 women, 72 men, mean age 32) with suspicion of acute appendicitis and a BMI between 18.5 and 30 (step 1). No further examination was recommended when ultrasound was positive for appendicitis, negative with low clinical suspicion, or demonstrated an alternative diagnosis. All other patients underwent LDCT (30mAs) (step 2). Standard intravenously enhanced CT (180mAs) was performed after indeterminate LDCT (step 3). Results: No further imaging was recommended after ultrasound in 84 (46%) patients; LDCT was obtained in 99 (54%). LDCT was positive or negative for appendicitis in 81 (82%) of these 99 patients, indeterminate in 18 (18%) who underwent standard CT. Eighty-six (47%) of the 183 patients had a surgically proven appendicitis. The sensitivity and specificity of the algorithm were 98.8% and 96.9%. Conclusions: The proposed algorithm achieved high sensitivity and specificity for detection of acute appendicitis, while reducing the need for standard CT and thus limiting exposition to radiation and to intravenous contrast medi

Quand référer aux urgences un patient présentant des douleurs abdominales?

When should a patient with abdominal pain be referred to the emergency ward? The following goals must be achieved upon managing patients with acute abdominal pain: 1) identify vital emergency situations; 2) detect surgical conditions that require emergency referral without further diagnostic procedures; 3) in "non surgical acute abdomen patients" perform appropriate diagnostic procedures, or in selected cases delay tests and reevaluate the patient after an observation period, after which a referral decision is made. Clues from the history and physical examination are critical to perform this evaluation. A good knowledge of the most frequent acute abdominal conditions, and identifying potential severity criteria allow an appropriate management and decision about emergency referral

Traumatisme de la rate: facteurs prédictifs d'échec du traitement non-opératoire

INTRODUCTION: Non-operative management of blunt splenic injury in adults has been applied with increasing frequency. However, predictive criteria for successful non-operative management are still a matter of debate. METHODS: we retrospectively reviewed all cases of blunt splenic injury in adult patients from 1997 to 2006. RESULTS: Of 190 patients with blunt splenic trauma (median age: 33 years, range 16-98), 43.7% (n=83) underwent emergency surgical intervention (Group I), and 56.3% (n=105) of patients were admitted for conservative treatment of splenic trauma. Conservative treatment was successful in 76.6% (n=82) (Group II), while 23.4% (n=25) of patients required a laparotomy (Group III). Ultimately, 43.2% of patients were successfully managed non-operatively, and 56.9% underwent laparotomy. Mechanism of injury was not significantly different among three groups. Group I patients presented significantly more frequently with hypovolemic shock (p<0.01), associated injuries (p<0.01), and high grade of splenic injury (p<0.01). All patients with active bleeding as evidenced by extravasation on CT scan, underwent exploratory laparotomy. Failure of non-operative management increased significantly with splenic trauma grade (grade I (0%), grade II (22.6%), grade III (27.6%) and grade IV (40%), (p<0.01) and with quantity of hemoperitoneum (10.4% of patients with small, 22.2% of patient with moderate, and 47.8% with large hemoperitoneum). The median interval for conservative treatment failure was 3 days (range: 1-15). Splenic injuries were operatively controlled by splenectomy (91.6%) and splenorrhaphy (8.4%). CONCLUSION: Suitability of adult patients with blunt splenic injury for non-operative management may be predicted at initial presentation, based on hemodynamic status and associated injuries. The quantity of hemoperitoneum and magnitude of splenic injury are predictive factors for failure of conservative treatment. Early definition of these factors may help identify those patients likely to be successfully treated without laparotomy

High-energy blunt pelvic ring injury incidence and polytrauma caseload in a single level I trauma center during COVID-19 related pseudo-lockdown measures: a retrospective cohort study based on a prospective registry

Abstract Background Pelvic ring injuries are potentially lethal lesions associated with polytrauma patients and need an efficient trauma team for their management. The purpose of this study was to evaluate the incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients in a single level I trauma center during the 2020 pseudo-lockdown period related to the Coronavirus pandemic, and to compare it with corresponding periods in 2014–2019 in order to better understand the need of organized and dedicated personnel and infrastructures. Methods This retrospective cohort study was based on data prospectively recorded into the institutional Severely Injured Patients’ Registry. Data were obtained for each year period (January 1st to December 31st) and corresponding pseudo-lockdown period (March 16th to June 19th). High-energy blunt pelvic ring injuries inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) pelvic ring injury presence. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; (3) penetrating, blast, burn and electrical injuries, drownings; (4) patients living outside the defined institution’s catchment area; and (5) any document attesting the patient’s will to not participate in any study. Polytrauma patients inclusion criteria were: (1) Registry entry between January 1st, 2014 and December 31st, 2020; (2) age ≥ 16 years old; and (3) Injury Severity Score ≥ 16. Corresponding exclusion criteria were: (1) death before admission; (2) transfer from another institution > 24 h after trauma; and (3) any document attesting the patient’s will to not participate in any study. Categorical variables were reported using proportions and continuous variables using medians and interquartile ranges. Because data were exhaustive for the authors’ level I trauma center, no inferential statistics were computed. Results The incidence of high-energy blunt pelvic ring injuries and the absolute number of polytrauma patients remained within range of previous years despite pseudo-lockdown measures. Conclusions These observations bring better knowledge about pseudo-lockdown’s impact on trauma and may help for future health strategy planning by pointing out the importance of maintaining the activity of level I trauma centers in terms of personnel and infrastructures

Outcome of surgery for rectal cancer in octogenarians

The aim of this study was to assess the outcome of surgery for rectal cancer in patients 80 years of age or more

Epidemiology of high-energy blunt pelvic ring injuries: a three-year retrospective case series in a level-I trauma center

Background: High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI. Hypothesis: Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year. Patients and methods: A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age &gt;16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database. Results: We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p&lt;0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates. Discussion: The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients. Level of evidence: Level III, retrospective cohort study.</p

Improvement of the effect of hepatocyte isograft in the Gunn rat by cotransplantation of islets of Langerhans

Hepatocyte transplantation (HcTX) has been investigated for many years as an alternative therapy to orthotopic liver transplantation to treat hepatic congenital enzymatic deficiency disease. The animal model most used is the Gunn rat, which presents a hyperbilirubinemia caused by the lack of uridine-diphosphate-glucuronyl-transferase. Some investigators have clearly described a hepatotrophic effect mediated by islets of Langerhans (IL) when transplanted with hepatocytes (Hc). In this study, the functional effect of cotransplanted IL on hepatocytes (co-HcTX) in Gunn rats in an isograft model is assessed

Isolement d'îlots de Langerhans porcins: évaluation de la fonction in vitro et in vivo

Pig islets are considered the best alternative to human islets in the treatment of insulin-dependent diabetes. Pigs could represent a potential islet donor for xenotransplantation in humans because of the close similarity between human and porcine insulin and the theoretically unlimited availability of porcine pancreas. From November 1991 to January 1997 we performed 221 pig islet isolations from 3 pig sources: group 1: minipigs (age 9-18 months) and white pigs (3-8 months), group 2: large white pigs (5-8 months), group 3: large white pigs (12-24 months). Islets were isolated according to a semi-automated method using enzymatic digestion and purification through discontinuous Euro-Ficoll gradients. The pancreases were surgically removed in our laboratory for group 1, while pancreases from groups 2 and 3 were removed at the slaughterhouse with an average warm ischemia time of 15 minutes. In vitro islet function was assessed by static incubations and perifusions, and in vivo islet function by transplantation under the kidney capsule of nude diabetic mice. The results were as follows: [table: see text] Insulin secretion increased twofold after in vitro glucose stimulation. We obtained restoration of euglycemia in diabetic mice which survived > 3 months after the graft and returned to diabetes after nephrectomy. This study shows that our isolated pig islets are viable and functional in vitro and in vivo after transplantation