Evolving Role of Endoscopic Retrograde Cholangiopancreatography in Management of Extrahepatic Hepatic Ductal Injuries due to Blunt Trauma: Diagnostic and Treatment Algorithms

Extrahepatic hepatic ductal injuries (EHDIs) due to blunt abdominal trauma are rare. Given the rarity of these injuries and the insidious onset of symptoms, EHDI are commonly missed during the initial trauma evaluation, making their diagnosis difficult and frequently delayed. Diagnostic modalities useful in the setting of EHDI include computed tomography (CT), abdominal ultrasonography (AUS), nuclear imaging (HIDA scan), and cholangiography. Traditional options in management of EHDI include primary ductal repair with or without a T-tube, biliary-enteric anastomosis, ductal ligation, stenting, and drainage. Simple drainage and biliary decompression is often the most appropriate treatment in unstable patients. More recently, endoscopic retrograde cholangiopancreatography (ERCP) allowed for diagnosis and potential treatment of these injuries via stenting and/or papillotomy. Our review of 53 cases of EHDI reported in the English-language literature has focused on the evolving role of ERCP in diagnosis and treatment of these injuries. Diagnostic and treatment algorithms incorporating ERCP have been designed to help systematize and simplify the management of EHDI. An illustrative case is reported of blunt traumatic injury involving both the extrahepatic portion of the left hepatic duct and its confluence with the right hepatic duct. This injury was successfully diagnosed and treated using ERCP

Coronary Embolic Phenomena: High-Impact, Low-Frequency Events

Coronary embolic phenomena (CEP) are difficult to diagnose yet carry potentially devastating clinical consequences. The goal of this chapter is to outline key processes and pathophysiologic mechanisms underlying CEP, primarily in the context of acute coronary syndrome (ACS). Not surprisingly, most reported cases of CEP occur in the left coronary circulation, but some right-sided events have been reported. Overall, causes include thrombotic, septic/infectious, neoplastic, valve-related, and iatrogenic mechanisms such as air embolization. Coronary angiography remains the definitive diagnostic and therapeutic approach, with computed tomography being increasingly utilized. Transthoracic echocardiography (TTE) should be part of a routine work up for patients with suspected CEP. Holter/event monitoring for atrial fibrillation may also be indicated in patients with embolic phenomena. Clinical management includes procedural restoration of coronary blood flow, followed by appropriate anticoagulation or antiplatelet therapy, in conjunction with appropriate treatment of any arrhythmias or other associated cardiac manifestations or conditions. Timely diagnosis, based on a high index of suspicion (especially in high-risk population) may be important in improving morbidity and mortality in affected patients. Since CEPs are often underdiagnosed and may be due to a number of heterogeneous causes, the need arises for increasing provider awareness of these important phenomena, as well as for the implementation of appropriate clinical management guidelines

Extracorporeal Membrane Oxygenation in Traumatic Injury: An Overview of Utility and Indications

Severe respiratory failure may develop in the trauma patient as a consequence of direct lung injury, in response to trauma‐associated systemic inflammatory response syndrome (SIRS), as a result of infection, or at times as an unintended consequence of the life‐saving management of the acute traumatic injury. Approximately 0.5% of all adult trauma patients develop some form of pulmonary dysfunction along the acute lung injury (ALI) – acute respiratory distress (ARDS) spectrum, with the incidence of severe respiratory failure reaching 10–20% in multisystem trauma victims. Of concern, mortality in patients with acute respiratory failure who go on to develop severe pulmonary dysfunction can be as high as 37–50% with the use of conventional therapeutic modalities. Extracorporeal membrane oxygenation (ECMO) has been proposed as a rescue strategy when less invasive primary or adjunctive attempts fail. Numerous case reports and single‐center studies demonstrate potential benefits of early implementation of veno‐venous (VV)‐ECMO for the treatment of severe respiratory failure associated with trauma or sequelae of trauma. In this clinical context, VV‐ECMO can be employed to correct for both ventilatory and oxygenation failure while allowing the treating physician to provide much needed rest to the patient\u27s lungs and permit healing to take place. The use of ECMO (mainly veno‐venous, with limited use of veno‐arterial circuits for cardiac indications) has been described in patients with severe chest injuries, traumatic pneumonectomy, bronchopleural fistulas, and various forms of respiratory failure refractory to conventional therapies

Correlations between biochemical testing, pathology findings and preoperative sestamibi scans: a retrospective study of the minimally invasive radioguided parathyroidectomy (MIRP) approach

BACKGROUND: Sestamibi imaging is the most widely used preoperative localization study for patients with hyperparathyroidism. Previous reports examine the relationship between the weight and volume of excised parathyroid glands and preoperative serum calcium and parathyroid hormone (PTH) levels. The aim of this study was to examine whether these variables correlate with the results of preoperative Sestamibi scans. MATERIAL AND METHODS: A retrospective review of 150 consecutive patients who underwent preoperative sestamibi imaging for primary hyperparathyroidism between 1998 and 2007 was performed. Variables studied included patient demographics, diagnostic test (sestamibi) results, operative/pathology findings and surgical outcome (normocalcaemia vs. persistent hypercalcaemia). Sestamibi scans were designated as either "negative" (NSS) or "positive" (PSS), where PSS correctly localized abnormal gland(s) enabling a focused neck exploration. The results of sestamibi imaging were correlated with calcium/PTH levels, weight/volume of excised glands and patient outcomes and demographics. RESULTS: Total excised gland weight/volume and preoperative serum calcium levels were significantly higher with PSS (all, p < 0.04). Higher preoperative serum calcium levels and greater total gland weight/volume were significantly associated with successful operative outcome (presence of postoperative normocalcaemia; all, p < 0.01). Factors associated with operative failure included multi-gland disease (p < 0.01) and NSS (p < 150 pg/mL) were associated with greater excised gland mass (p < 0.05) and volume (p < 0.05). Male gender was associated with higher preoperative serum calcium levels (p < 0.02). Of interest, patients with single-gland disease had significantly higher preoperative PTH levels than patients with multi-gland disease (155 vs. 109 pg/mL, p < 0.05). CONCLUSION: Positive sestamibi scans are associated with heavier/larger parathyroid glands and higher preoperative serum calcium levels. Male gender was associated with higher preoperative serum calcium levels, while single-gland disease was associated with higher preoperative PTH levels. In addition, successful surgical outcome was associated with higher preoperative serum calcium levels and with greater excised parathyroid gland mass/volume. Surgical failure was associated with multi-gland disease and negative sestamibi

On magnetic fluctuation spectra in the solar wind and the influence of mode dispersion

Magnetic fluctuation power spectra in the solar wind are commonly observed to have a power-law form with a spectral index s = 5/3 at frequencies lower than about 1 Hz. This characteristic feature of magnetic fluctuation spectra defines what is called the inertial range and may be described, in wavenumber space, by Kolmogorov diffusion. For higher frequencies, it has been suggested that collisionless damping of Alfven and magnetosonic waves leads to steeper power-laws; this regime is sometimes labeled as the dissipation range. Here we argue, based on numerical calculations, that it is more likely that the observed steeper power-laws result from an increase in the wavenumber diffusion rate caused by whistler-like dispersion than from collision-less damping. The calculations lead to the prediction, that this broken power-law feature of magnetic fluctuation spectra is only observable in low-{beta}{sub p} plasmas

The helicase Ded1p controls use of near-cognate translation initiation codons in 5' UTRs.

The conserved and essential DEAD-box RNA helicase Ded1p from yeast and its mammalian orthologue DDX3 are critical for the initiation of translation1. Mutations in DDX3 are linked to tumorigenesis2-4 and intellectual disability5, and the enzyme is targeted by a range of viruses6. How Ded1p and its orthologues engage RNAs during the initiation of translation is unknown. Here we show, by integrating transcriptome-wide analyses of translation, RNA structure and Ded1p-RNA binding, that the effects of Ded1p on the initiation of translation are connected to near-cognate initiation codons in 5' untranslated regions. Ded1p associates with the translation pre-initiation complex at the mRNA entry channel and repressing the activity of Ded1p leads to the accumulation of RNA structure in 5' untranslated regions, the initiation of translation from near-cognate start codons immediately upstream of these structures and decreased protein synthesis from the corresponding main open reading frames. The data reveal a program for the regulation of translation that links Ded1p, the activation of near-cognate start codons and mRNA structure. This program has a role in meiosis, in which a marked decrease in the levels of Ded1p is accompanied by the activation of the alternative translation initiation sites that are seen when the activity of Ded1p is repressed. Our observations indicate that Ded1p affects translation initiation by controlling the use of near-cognate initiation codons that are proximal to mRNA structure in 5' untranslated regions

Uszkodzenie nadnerczy w następstwie tępych urazów: wskaźnik ciężkości doznanych obrażeń

Introduction: Adrenal gland injuries (AGI) are seen increasingly frequently owing to advances in modern imaging techniques. This study describes a series of patients with blunt AGI, with the emphasis on AGI as a marker of injury severity, CT-radiographic classification of AGI and associated injury patterns. Material and methods: A retrospective review of blunt trauma patients with AGI was performed. Variables examined included demographics, mechanism of injury, length of hospital and ICU stay, clinical status on admission, AGI characteristics, associated injuries, complications, procedures, mortality and discharge disposition. Results: There were 29 AGI patients with a mean injury severity score of 25. The most common injury mechanisms were motor-vehicular collisions (15/29) and falls (5/29). Right-sided AGI (16/29) outnumbered left-sided (12/29) injuries. The most common CT-radiographic types of AGI were adrenal gland contusions and lacerations with limited "blush". While patterns of injuries differed between right and left-sided AGI, the mean number of injuries did not. The most common associated injuries included extremity (21/29), rib (20/29) and spinal fractures (18/29). Common procedures included orthopaedic fixation (10/29), vena cava filter (8/29) and tracheostomy (5/29). A median of two complications per patient was reported, including adrenal insufficiency in two patients. Mortality was 17%. The median hospital and ICU length of stay were 15 and 12 days, respectively. Conclusions: Adrenal gland injury is associated with significant morbidity and mortality. With modern imaging modalities capable of reliably detecting adrenal injury, the presence of AGI should be considered a marker of overall injury severity. The authors provide a CT-radiographic classification of adrenal injuries.Wstęp: W związku z postępem w zakresie nowoczesnych metod obrazowania coraz częściej stwierdza się uszkodzenia nadnerczy (AGI, adrenal gland injuries). W tym badaniu opisano grupę chorych, którzy doznali uszkodzenia nadnerczy w wyniku tępego urazu. Zwrócono szczególną uwagę na AGI jako wskaźnik ciężkości odniesionych obrażeń, klasyfikację AGI na podstawie tomografii komputerowej i charakter współistniejących obrażeń. Materiał i metody: Przeprowadzono retrospektywną analizę danych pacjentów, którzy doznali AGI w wyniku tępego urazu. W badaniu uwzględniono dane demograficzne, mechanizm powstania urazu, czas hospitalizacji oraz pobytu na oddziale intensywnej opieki medycznej, stan kliniczny w chwili przyjęcia do szpitala, cechy AGI, doznane obrażenia, powikłania, zastosowane procedury medyczne, odsetek zgonów i dalsze postępowanie. Wyniki: Do badania włączono 29 osób z AGI, u których średnia ocena ciężkości obrażeń wynosiła 25. Najczęstszymi przyczynami urazu były wypadki motocyklowe (15/29) i upadki (5/29). Liczba prawostronnych AGI (16/29) była wyższa niż liczba uszkodzeń lewostronnych (12/29). Najczęściej stwierdzanym rodzajem uszkodzeń AGI w badaniu tomograficznym było stłuczenie i rozdarcie narządu z niewielkim krwawieniem. Chociaż charakter uszkodzeń różnił się w zależności od prawo- lub lewostronnej lokalizacji AGI, średnia liczba uszkodzeń była taka sama. Najczęstszymi współwystępującymi obrażeniami były złamania kończyn (21/29), żeber (20/29) i kręgów (18/29). Do najczęściej wykonywanych procedur należały: unieruchomienie ortopedyczne (10/29), wszczepienie filtra do żyły głównej (8/29) i tracheostomia (5/29). Mediana liczby powikłań u poszczególnych chorych wynosiła 2 (włączając niewydolność nadnerczy u 2 osób). Odsetek zgonów wynosił 17%. Mediana okresu hospitalizacji i pobytu na oddziale intensywnej opieki medycznej wynosiła odpowiednio 15 i 12 dni. Wnioski: Uszkodzenie nadnerczy wiąże się ze znaczną chorobowością i śmiertelnością. Dostępne obecnie nowoczesne metody obrazowania umożliwiają wykrycie uszkodzeń nadnerczy. Należałoby rozważyć przyjęcie obecności AGI jako markera ciężkości doznanych obrażeń. Autorzy przedstawili klasyfikację uszkodzeń nadnerczy na podstawie badań tomograficznych

The Process of Organ Donation from Non-Living Donors: A Case-Based Journey from Potential Donor Identification to Organ Procurement

Each year, thousands of people worldwide succumb to end-organ failure while awaiting life-saving transplantation procedures. The shortage of organs continues with no signs of easing in the foreseeable future. The availability of organs from living donors continues to be constrained. At the same time, the cumulative knowledge of organ preservation is advancing steadily resulting in an enhanced ability to utilize a growing number of previously unsuitable tissue and organ gifts. Our ability to procure and preserve more organs is accompanied by the increasing use of so-called “expanded criteria” donors, or those whose organs may not have been suitable without modern advances in organ preservation science. Within the overall context of organ donation from non-living donors, the importance of physiologic and end-organ optimization cannot be understated. This chapter discusses our current state of understanding of optimized organ procurement approaches derived from practical experiences and “lessons learned” at a high-performing, community-based tertiary referral hospital

Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More

Foreign intravascular object embolization (FIOE) is an important, yet underreported occurrence that has been described in a variety of settings, from penetrating trauma to intravascular procedures. In this chapter, the authors will review the most common types of FIOEs, including bullet or “projectile” embolism (BPE), followed by intravascular catheter or wire embolization (ICWE), and conclude with intravascular noncatheter object (e.g., coil, gelatin, stent, and venous filter) migration (INCOM). In addition to detailed topic-based summaries, tables highlighting selected references and case scenarios are also presented to provide the reader with a resource for future research in this clinical area