Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review

<p>Abstract</p> <p>Background and method</p> <p>The aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.</p> <p>Case presentation</p> <p>We present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.</p> <p>Conclusion</p> <p>Although the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.</p

Association between contrast extravasation on computed tomography scans and pseudoaneurysm formation in pediatric blunt splenic and hepatic injury: A multi-institutional observational study

PURPOSE: We aimed to examine the association between contrast extravasation (CE) on initial computed tomography (CT) scan and pseudoaneurysm (PSA) development in pediatric blunt splenic and/or liver injury. METHODS: We conducted a multi-institutional retrospective study in cases of blunt splenic and/or hepatic injury who underwent an initial attempt of nonoperative management. A logistic regression model was used to compare PSA formation and CE on initial CT scan, and the area under the receiver operating characteristic curve (AUC) with and without CE was used to assess the predictive performance of CE for PSA formation. RESULTS: Of 236 cases enrolled from 10 institutions, PSA formation was observed in 17 (7.2%). Multivariate analysis showed a significant association between CE on initial CT scan and increased incidence of PSA formation (odds ratio, 4.96; 95% confidence interval, 1.37-18.0). There was no statistically significant association between the grade of injury and PSA formation. The AUC improved from 0.75 (0.64-0.87) to 0.80 (0.70-0.91) with CE. CONCLUSION: Active CE on initial CT scan was an independent predictor of PSA formation. Selective use of follow-up CT in children who showed CE on initial CT may provide early identification of PSA formation, regardless of injury grade. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III

The impact of pre-injury controlled substance use on clinical outcomes after trauma

A disproportionately high percentage of trauma patients use controlled substances, and they often co-ingest multiple drugs. Previous studies have evaluated the effect of individual drugs on clinical outcomes following trauma. However, the impact of all drugs included in a comprehensive screening panel has not yet been compared in a single cohort of patients

Mechanisms of injury in adolescent trauma patients with a positive marijuana screen.

BACKGROUND Marijuana use among adolescents may have increased after its legalization in the United States. An association between violence and marijuana use in adults has been demonstrated in previous reports. We hypothesized that adolescent trauma patients presenting with a positive marijuana screen (pMS) are more likely to have been injured by gunfire or knives and will have more severe injuries overall, compared to patients with a negative marijuana screen (nMS). METHODS The 2017 Trauma Quality Improvement Program database was queried for adolescent (13-17 years old) pMS patients and compared to adolescents who tested negative for all substance/alcohol. Patients with positive polysubstance/alcohol were excluded. RESULTS From 8257 adolescent trauma patients, 2060 (24.9%) had a pMS with a higher rate of males in the pMS group (76.3% vs 64.3%, P < .001). The pMS group presented more frequently after gun (20.3% vs 7.9%, P < .001) or knife trauma (5.7% vs 3.0%, P < .001) and less frequently after falls (8.9% vs 15.6%, P < .001) and bicycle collisions (3.3% vs 4.8%, P = .002). The rate of serious thoracic injury (AIS ≥3) was higher for pMS patients (16.7% vs 12.0%, P < .001), and more pMS patients required emergent operation (14.9% vs 10.6%, P < .001). DISCUSSION In our adolescent patient population, one quarter tested positive for marijuana. These patients are more likely to be injured by guns and/or knives suffering serious injuries, and often require immediate operative intervention. A marijuana cessation program for adolescents can help improve outcomes in this high-risk patient group

Methamphetamine use associated with gun and knife violence: A matched cohort analysis

IntroductionThere may be an association between violence and methamphetamine use. We hypothesized that trauma patients screening positive for methamphetamines are more likely to present after penetrating trauma and have increased mortality.MethodsThe 2017-2019 TQIP was used to 1:2 match methamphetamine (meth+) patients to patients testing negative for all drugs (meth-). Patients with polysubstance/alcohol use were excluded. Bivariate and logistic regression analyses were performed.ResultsThe rate of methamphetamine use was 3.1&nbsp;%. After matching, there was no difference in vitals, injury severity score, sex, and comorbidities between cohorts (all p&nbsp;&gt;&nbsp;0.05). Compared to meth-, the meth+ group was more commonly sustained penetrating trauma (19.8&nbsp;% vs. 9.2&nbsp;%, p&nbsp;&lt;&nbsp;0.001) with stab-wounds being the most common penetrating mechanism (10.5&nbsp;% vs. 4.5&nbsp;%, p&nbsp;&lt;&nbsp;0.001). The meth+ group more commonly underwent surgery immediately from the emergency department (ED) (20.3&nbsp;% vs. 13.3&nbsp;%, p&nbsp;&lt;&nbsp;0.001). The associated risk of death in the ED was higher for the meth+ group (OR 2.77, CI 1.45-5.28, p&nbsp;=&nbsp;0.002), however, the risk was similar for patients that were admitted or received an operation (p&nbsp;=&nbsp;0.065).ConclusionTrauma patients using methamphetamine more commonly presented after gun or knife violence and required immediate surgical intervention. They also have increased associated risk of death in the ED. Given these serious findings, a multidisciplinary approach in helping curtail the worsening epidemic of methamphetamine use appears warranted as it is related to penetrating trauma and outcomes.Level of evidenceIV

Citation versus disruption in the military: Analysis of the top disruptive military trauma research publications

BackgroundBibliometric analysis of surgical research has become increasingly prevalent. Citation count (CC) is a commonly used marker of research quality, but may overlook impactful military research. The disruption score (DS) evaluates manuscripts on a spectrum from most innovative with more positive scores (disruptive [DR]) to most entrenched with more negative scores (developmental; DV). We sought to analyze the most DR and DV versus most cited research in military trauma.MethodsTop trauma articles by DS and by CC were identified via professional literature search. All publications in military journals were included. Military trauma-related keywords were used to query additional top surgical journals for military-focused publications. Publications were linked to the iCite NIH tool for CC and related metrics. The top 100 DR and DV publications by DS were analyzed and compared with the top 100 articles by CC.ResultsOverall, 32,040 articles published between 1954 and 2014 were identified. The average DS and CC were 0.01 and 22, respectively. Most articles were published in Mil Med ( 68%). The top 100 DR articles were frequently published in Mil Med (51%) with a mean DS of 0.148. Of these, the most cited article was only the 40th most disruptive. The top 100 CC articles averaged a DS of 0.009 and were commonly found in J Trauma (53%). Only five publications were on both the top 100 DR and top 100 CC lists; 19 were on both the top DV and CC lists. Citation count was not correlated with DR ( r = -0.134; p = 0.07) and only weakly correlated with DV ( r = 0.215; p = 0.003).ConclusionDS identifies publications that changed military paradigms and future research directions previously overlooked by citation count alone. The DR and DV articles are distinct with little overlap between highly cited military articles. Multiple bibliometric measures should be employed to avoid overlooking impactful military trauma research.Level of evidenceDiagnostic Test or Criteria; Level IV

American Association for the Surgery of Trauma Prevention Committee review: Family Justice Centers—a not-so-novel, but unknown gem

The American College of Surgeons Committee on Trauma requires that trauma centers demonstrate adequate financial support for an injury prevention program as part of the verification process. With the ongoing challenges that arise with important social determinants of health, trauma centers have the important task of navigating a patient through the complex process of obtaining services and tools for success. This summary from the American Association for the Surgery of Trauma Prevention Committee focuses on a model that has been present for several years, but has not been brought to full awareness in the trauma world. It highlights the importance of the Family Justice Center concept that brings a multitude of organizations under one roof, thus eliminating the hurdles encompassed by trauma patients, seeking life-changing resources necessary to mitigate the impact of both community violence exposure and intimate partner/domestic violence. It discusses the potential benefits of a partnership between trauma centers and Family Justice Centers and similar models. Finally, it also raises awareness of important programmatic evaluation research required in the arena of injury prevention targeting a population whose outcomes are difficult to measure