Right-sided "trapdoor" incision provides necessary exposure of complex cervicothoracic vascular injury: a case report

Combined cervicothoracical vascular traumas are very uncommon, mostly resulting from penetrating injuries. These injuries are accompanied with very high morbidity and mortality rates. In this manuscript we present a case of hemodinamycally unstable trauma patient whose major injury was penetrating trauma of both cervical and mediastinal major vessels. The standard surgical approach of median sternotomy and neck incision was insufficient, and the patient's instability forced the authors to improvise previously not described right-sided trap-door thoracomy. Incorporation of such incision in the surgical arsenal may be very effective in selective case

Selection of patients with severe pelvic fracture for early angiography remains controversial

<p>Abstract</p> <p>Background</p> <p>Patients with severe pelvic fractures represent about 3% of all skeletal fractures. Hemodynamic compromise in unstable pelvic fractures is associated with arterial hemorrhage in less than 20% of patients. Angiography is an important tool in the management of severe pelvic injury, but indications and timing for its performance remain controversial.</p> <p>Methods</p> <p>Patients with major pelvic fractures [Pelvic Abbreviated Injury Score (AIS) ≥ 3] admitted to two high volume Trauma Centers from January 2000 to June 2005 were identified and divided into two groups: Group I patients did not undergo angiography, Group II patients underwent angiography with/without embolization. Demographics, hemodynamic status on admission, concomitant injuries, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), pelvic AIS, blood requirement before and after angiography, arterial blood gases and mortality were evaluated. Patients with an additional reason for hemodynamic instability were excluded.</p> <p>Results</p> <p>Charts of 106 patients were retrospectively reviewed. Twenty nine patients (27.4%) underwent angiography. Bleeding vessel embolization was performed in 20 (18.9%) patients. Patients who underwent angiography had a significantly higher pelvic AIS and a lower Base Excess level on admission. A blood transfusion rate of greater than 0.5 unit/hour was found to be a reliable indicator for early angiography.</p> <p>Conclusion</p> <p>A high pelvic AIS, amount of blood transfusions and decreased BE level should be considered as an indicators for early angiography in patients with severe pelvic injury.</p

When all computers shut down: the clinical impact of a major cyber-attack on a general hospital

ImportanceHealthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated.ObjectiveThis study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations.SettingThis study was conducted on a public, general, and acute care referral university teaching hospital.MethodsWe report the different recovery measures on various hospital clinical activities and their impact on clinical work.ResultsThe system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial.Conclusions and relevanceThe risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work

Role of ER Stress Response in Photodynamic Therapy: ROS Generated in Different Subcellular Compartments Trigger Diverse Cell Death Pathways

We have analyzed the molecular mechanisms of photoinduced cell death using porphyrins with similar structure differing only in the position of the ethylene glycol (EG) chain on the phenyl ring. Meta- and para-positioned EG chains targeted porphyrins to different subcellular compartments. After photoactivation, both types of derivatives induced death of tumor cells via reactive oxygen species (ROS). Para derivatives pTPP(EG)4 and pTPPF(EG)4 primarily accumulated in lysosomes activated the p38 MAP kinase cascade, which in turn induced the mitochondrial apoptotic pathway. In contrast, meta porphyrin derivative mTPP(EG)4 localized in the endoplasmic reticulum (ER) induced dramatic changes in Ca2+ homeostasis manifested by Ca2+ rise in the cytoplasm, activation of calpains and stress caspase-12 or caspase-4. ER stress developed into unfolded protein response. Immediately after irradiation the PERK pathway was activated through phosphorylation of PERK, eIF2α and induction of transcription factors ATF4 and CHOP, which regulate stress response genes. PERK knockdown and PERK deficiency protected cells against mTPP(EG)4-mediated apoptosis, confirming the causative role of the PERK pathway

The risk of deterioration in GCS13-15 patients with traumatic brain injury identified by CT imaging : a systematic review and meta-analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED

Acute Appendicitis in the Elderly: A Nationwide Retrospective Analysis

Background: Acute appendicitis (AA) in older individuals remains understudied. We aimed to assess AA characteristics in patients older than 60 years and evaluate the impact of comorbidities. Methods: This retrospective study analyzed data from the American National Inpatient Sample between 2016 and 2019 to compare AA characteristics in patients younger and older than 60 years. Results: Of the 538,400 patients included, 27.5% were older than 60 years. Younger patients had a higher appendectomy rate (p p Conclusions: This study highlights a higher incidence of AA in older individuals than previously reported, with comorbidities posing differing risks for infections between age groups

Perforation of the gallbladder into the abdominal wall: A rare manifestation of biliary disease

A 54-year-old man was admitted to our surgery department complaining of right upper quadrant abdominal pain. The working diagnosis of acute cholecystitis was based on the clinical picture, laboratory tests, and ultrasound findings. Because of the uncommon course of the disease, computed abdominal tomography was performed, showing multiple stones in the anterior abdominal wall. On surgery, the fistula, containing stones and pus connecting the gallbladder and the abdominal wall muscles, was found

New Technique of Direct Intra-abdominal Pressure Measurement

To determine the efficacy of 14-Fr PVC round drain in the direct measurement of intra-abdominal pressure. Methods: Fifty consecutive patients undergoing elective laparoscopic surgery in a tertiary teaching hospital were included in this pilot study. Patients underwent laparoscopic cholecystectomy, appendectomy, splenectomy, colectomy and Nissen fundoplication. After creation of pneumoperitoneum and insertion of the trocars as indicated by the operation, a 14-Fr PVC round drain was inserted into the abdominal cavity via one of the laparoscopic ports. It was then connected under sterile conditions to the invasive blood pressure measurement system. Intra-abdominal pressure was gradually increased. Intra-abdominal pressures as measured through the round PVC drain were compared to those measured by the laparoscopic insufflator at 5, 8, 12 and 24 mmHg. Results: Two hundred measurements using each of the two methods were performed and correlated. The correlation coefficient was 0.996. No complications were observed with this new technique. Conclusion: Direct measurement of intra-abdominal pressure using 14-Fr PVC round drain is a newly described technique that is simple, fast and credible. Future investigation will be needed to confirm the reliability of this method during postoperative follow-up of intra-abdominal pressures in selected patients

Burkitt's Lymphoma: An Unusual Cause of Obstructive Jaundice

Biliary obstruction secondary to malignancy is a common clinical problem. Rarely, biliary obstruction is due to non-Hodgkin's lymphoma. Obstructive jaundice in these patients usually presents late in the course of the disease. Burkitt's lymphoma is a subtype of non-Hodgkin's lymphoma. Unlike other forms of non-Hodgkin's lymphoma, Burkitt's lymphoma presents as an extranodal disease. We present the case of a patient suffering from non-endemic Burkitt's lymphoma whose initial presenting symptom was obstructive jaundice