TS15PUNCOMMON ABDOMINAL HEMORRHAGE DUE TO BLUNT TRAUMA: BLENDING FROM AN ASYMPTOMATIC ABDOMINAL TUMOR INJURY – A CASE REPORT

Asymptomatic tumors are not uncommon, may be diagnosed during clinical examination or during surgical interventions for other purposes such as treatment of a hemorrhage due a blunt trauma. Case report 6 year‐old boy had fallen, hitting his abdomen against a rock, and arrived at hospital ten hours later. Initial assessment he was complaining of diffuse abdominal pain; his physical examination showed: respiratory rate: 16 mov/min, blood pressure: 100 × 80 mmHg, heart rate: 100 bat/min, and Glasgow coma score: 15. His abdomen was distended, with guarding and rebound tenderness, and had a palpable mass. FAST ultrasound was positive; and Ct‐scan showed an abdominal mass with 15 × 12 × 7 cm dimension, and moderate amount of free blood in the abdominal cavity. Laboratory tests showed: hemoglobin 9.9 mg/dl, hematocritic 28.8%, white blood cells 6.900 cel/dl. Midline laparotomy was performed, a large, injured and bleeding mesenteric mass was found encircling superior mesentery artery and several small bowel loops; 500 ml of free blood was found in the peritoneal cavity. Mesenteric mass was partially removed with a segment of the small bowel. Findings of anatomico‐pathologic examination revealed an intestinal Burkitt lymphoma, with mesenteric linfonodes. Patient had an uneventful postoperative course, and started with quimotherapy. Comments This case report shows an unusual traumatic abdominal blending that could not be clearly diagnosed before laparotomy was performed. The emergency of this case was bleeding control, decision to remove mass was taken only for this purpose, and not to treat the tumor. As removal of the whole mass was impossible, a partial removal was performed.     

PRIMARY ADENOCARCINOMA IN A COLONIC ‘OESOPHAGEAL’ SEGMENT

Book reviews in this article: A case of primary adenocarcinoma of the colon in a segment used to reconstruct after an oesophageal resection is reported. The original lesion was a relatively advanced adenocarcinoma of the gastro-oesophageal junction. An ACPS ‘C’ colon carcinoma was diagnosed 12 years later. A curative resection was achieved. The literature is reviewed in regard to late complications in colonic interpositions, including primary carcinomas.     

'MRS L.‘S CASE’: A CELEBRATED SOUTH AUSTRALIAN SURGICAL CASE

This paper concerns a dispute at the adelaide hospital in september 1896 between professor archibald watson, pathologist, honorary consulting surgeon and sole remaining university teacher at the hospital, and alexander disney leith napier. Who had arrived from england to fill the place of the honorary surgeons who had resigned from the hospital. Watson accused napier of incompetence in his management of ‘mrs l.’, who died after a femoral hernia operation. Mrs l had a form of internal hernia causing intestinal obstruction, whereas all the medical attendants, including watson, originally thought an old femoral hernia was the cause of her illness. By fortuitous coincidence the operation on the femoral hernia could have cured the internal hernia if the band of omentum attached to the femoral hernia had been divided. Watson became aware of the band at the post-mortem and then asserted that the operation should have taken it into account. Napier complained to the board of the hospital, alleging that watson had misrepresented the facts when he conducted the post-mortem on the patient and that he was disloyal to the hospital. The board found the complaint proved and invited watson to resign; he declined and was dismissed. Undaunted, watson circulated a privately printed pamphlet (entitled ‘mrs l.'s case’), which re-stated the events of the case and graphically described his post-mortem findings. It was submitted to the chairman of a select committee of the legislative council of south australia established to review the running of the hospital. The committee recommended the setting up of a royal commission but the government let the matter lapse. The opportunity for continued clinical teaching of students at the adelaide hospital, already poor when this dispute started, was lost. Only the balm of time and the spirit of compromise healed the rift and allowed clinical teaching to begin again in 1900. The lessons in this cautionary tale are considered.     

‘CHRONIC WORKLOAD’, ‘NEED FOR CONTROL’ AND ‘VITAL EXHAUSTION’ IN PATIENTS WITH MYOCARDIAL INFARCTION AND CONTROLS: A COMPARATIVE TEST OF CARDIOVASCULAR RISK PROFILES

In view of a growing number of different psychosocial cardiovascular risk profiles which have been developed and tested over the past 30 years, it is now timely to assess their interrelationship in terms of convergent validity and differential predictive power. Three such profiles, ‘chronic workload’, ‘need for control’ and ‘vital exhaustion’, are analysed using data from a case-control study of 79 hospitalized male patients following a first acute myocardial infarction (AMI) (mean age 52.9) and of 132 controls hospitalized for surgical (mean age 52.0). As predicted by theory, all three concepts significantly discriminated between AMI patients and controls both in univariate analyses and after adjusting for important confounders (age, anginal pain, cigarette smoking). However, when controlling for ‘vital exhaustion’ (OR=3.80, p=0.02), the effect of the critical factor ‘immersion’ of the concept ‘need for control’ lost its statistical significance (OR=2.11, p=0.24), whereas the powerful independent effect of ‘chronic workload’ (OR=8.98, p=0.01) was maintained. No interaction effects on the criterion produced by the three concepts were observed. The data confirm the validity of selected elements of the effort–reward imbalance model and contribute to the specification of the coronary-prone coping career. Therefore, they encourage more intense comparative testing of related concepts in research on psychosocial cardiovascular risk profiles. © 1997 by John Wiley & Sons, Ltd.     

TS19PSTUDY OF THE PATTERN OF INTRA‐ABDOMINAL SOLID ORGAN INJURY – A FIVE‐YEAR CENTRAL AUSTRALIA EXPERIENCE

Purpose This study aimed to evaluate the pattern of solid intra‐abdominal organ injuries in Central Australia, with focus on the mechanism of injury, Injury Severity Score (ISS), distribution of injury, role of surgical intervention and their outcome. It aimed to assess if difference exists in the above perimeters between the indigenous and non‐indigenous population. Methodology This is a retrospective analysis of a selected group of patients as identified by ICD Codes. Database has been created for patients admitted with renal, pancreatic, hepatic and splenic trauma over a five‐year period (2001–2005). Data on demographics, mechanism of injury, distribution of injury, length of stay and ISS has been collected. Results Seventy‐one patients has been identified, with 51 (72%) indigenous and 20 (28%) non‐indigenous. 29 patients (41%) were involved in a Motor Vehicle Accident and 33 (46%) were assaulted. There is no statistical difference with the distribution of injury and ISS amongst indigenous and non‐indigenous populations. However there appears to have a higher incidence of surgical intervention associated with the indigenous group (28.8% versus 12.5%). This may be explained by the compliance rate as 29.4% of indigenous patients left against medical advice as compared with 0% with the non‐indigenous group. Conclusion The mechanism, pattern and severity of injury appear to be comparable amongst the indigenous and non‐indigenous population in Central Australia. However there is a difference in their incidence of surgical intervention. ISS may not be as useful in prediction for need for intervention in this group and a different approach to trauma management may need to be tailored to this population.     

VALUE OF THE PROSPECTIVE ‘BEFORE AND AFTER’ STUDY AS A METHODOLOGY TO EVALUATE OUTCOME IN A TRAUMA CENTRE

A series of interventions (administrative, clinical and educational) was introduced to improve the quality of trauma care at Royal Prince Alfred Hospital, the designated trauma centre for the Central Sydney Area Health Service (CSAHS). A prospective, ‘before and after’ study was conducted to assess changes in outcome following the introduction of these measures. The trauma centre survival rate for patients admitted with serious injury (Injury Severity Scores > 15) increased significantly, from 72% in the nine months before trauma centre designation to 89% in the nine months after (P= 0.005). The peer review designated, potentially avoidable death rate did not change significantly over the two study periods, remaining in the 20–30% range. Similarly the unexpected death rate (TRISS) did not change significantly, remaining in the 20–45% range. A trend to a lower trauma centre mortality in those arriving with a systolic blood pressure 90 mmHg was noted. Seven out of 14 patients ‘at risk’ from exsanguination died in the first 9 months compared with one out of seven in the second 9 months (P = 0.17). An unexpected finding was a change in the degree of injury severity and physiological status in patients arriving at the trauma centre. The Injury Severity Scores were significantly lower (P= 0.008) and the Revised Trauma Scores significantly higher (P= 0.0006) in the latter 9 months of the study. It was concluded that the improved trauma centre survival rate was a reflection of a reduced hospital mortality from haemorrhagic shock in conjunction with a lesser degree of injury severity in patients admitted from the CSAHS.     

GS10AN ACUTE CARE SURGICAL SERVICE – A CHANGE IN PARADIGM

Background The provision of acute surgical care in the public sector is becoming increasingly more difficult due to the limitation of resources. The lack of predictability of access to theatres during the working day has the effect of displacing elective cases or forcing some acute cases to be performed after hours. An Acute Care Surgical Service was constructed at the Prince of Wales Hospital so as to provide acute surgery in a more timely and efficient manner. Methods A roster of 8 general surgeons was constructed to provide onsite service during the working day and on call service after hours for a 52 week period. An acute care ward of 4 beds and an operating theatre was placed under the control of the Acute Care Surgeon (ACS). At the end of the ACS roster all patients whose treatment was incomplete were handed on to the next rostered ACS. Patient data and theatre utilisation data was prospectively collected and compared to the preceding 52 week period. Data was analysed using unpaired t‐test. Results Emergency theatre utilization during the day increased from 55% to 70%. There was a 15% reduction in acute care operating after hours. Fewer cases were done between midnight and 0800. There was more efficient use of the entire theatre block suggesting a significant cultural change. Staff satisfaction was high. Conclusion On site consultant driven surgical leadership has provided significant positive change to the provision of Acute Surgical Care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.     

BS19BRCA 1 & BRCA2 GENE TESTING FOR BREAST AND OVARIAN CANCER IN AUSTRALIA AND NEW ZEALAND – THE GTG EXPERIENCE

Over the past three years, Genetic Technologies Ltd (GTG) has been providing a fee for service (commercial) BRCA 1 & 2 genetic pathology testing service. Full gene screening isperformed within 8 weeks and fast tracking of testing for clinical management purposes cab be performed in 2–4 weeks. We present a schema for testing that utilizes robotics, LIMS, automated DNA sequencing, computer aided analysis and ISO15189 / NATA / RCPA accredited test protocols. Despite the active testing that has been carried out of the BRCA1 & 2 genes worldwide over the past decade, it is interesting to note that significant numbers of new (not previously reported) BRCA mutational events and gene variants have been identified in our testing service – the GTG experience.     

M.K. Jankowski,P.P. Schnurr,G.A. Adams,B.L. Green,J.D. Ford,and M.J. Friedman. ‘A mediational model of PTSD in World War II veterans exposed to mustard gas’. Journal of Traumatic Stress 17(4) 2004, 303–310

The original article to which this Erratum refers was published in the Journal of Traumatic Stress 17(4) 2004, 303–310.