What's new in resuscitation strategies for the patient with multiple trauma?

The last decade has seen a sea change in the management of major haemorrhage following traumatic injury. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, haemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy and stabilise the patient as early as possible in a critical care setting. This narrative review examines the background to these changes in resuscitation practice, discusses the central importance of traumatic coagulopathy in driving these changes particularly in relation to the use of high FFP:RBC ratio and explores methods of predicting, diagnosing and treating the coagulopathy with massive transfusion protocols as well as newer coagulation factor concentrates. We discuss other areas of trauma haemorrhage management including the role of hypertonic saline and interventional radiology. Throughout this review we specifically examine whether the available evidence supports these newer practices.     

What's new in the management of acute pancreatitis?

Acute severe pancreatitis remains a disease with multiple complications and high mortality rates. The body of knowledge about clinical pancreatitis is being subjected to rigorous evidence-based analysis, and relevant, practical guidelines have been issued. Great efforts are being made to identify and profile the mediators involved in the systemic hyperinflammatory response to acute pancreatic injury. Lexipafant, a platelet-activating factor antagonist that showed promising results in initial trials, failed to reduce the incidence of new organ failures or mortality in a large double-blind study. The search for an early and accurate prognostic marker for severity persists, with urinary trypsinogen activation peptide as a potentially suitable candidate. Patients with acute pancreatitis do not benefit from anti-secretory therapy with octreotide. Percutaneous, radiological, drainage techniques may eventually play an important role in the management of infected necrosis.     

What's new in the management of penile cancer?

PURPOSE OF REVIEW: Penile cancer is a rare disease. This has led to little in the way of therapeutic advances in the last two decades. Efforts have been made to minimize the use of disfiguring or morbid procedures in treating the primary tumor or managing the inguinal region. In addition, new insights have been gained into multimodal therapy for treating metastatic disease. We reviewed the literature published during the past two years to define the recent insights into the diagnosis and management of penile cancer. RECENT FINDINGS: Surveillance, Epidemiology and End Results Program data revealed poor outcome among African-American patients compared with Caucasians with penile cancer. Risk factors, including human papilloma virus, HIV, and the practice of circumcision have been reassessed. To improve diagnosis and staging, new modifications in imaging have been developed including magnetic resonance imaging with artificial erection. In addition, the technique of dynamic sentinel node biopsy has been refined. Pathologic features of the primary tumor (i.e., stage, grade, vascular invasion) assist in identifying patients who would benefit from lymphadenectomy. Organ-sparing treatments using laser ablation and reconstructive procedures to preserve glans or phallus length have also been developed. Systemic chemotherapy regimens, including consolidative approaches with surgery or radiotherapy, are discussed for advanced penile cancer. SUMMARY: Penile cancer remains a rare disease. Epidemiologic insights reveal provocative findings with respect to risk factors and racial differences in the outcome. Recent literature provides information that will aid urologists in (1) minimizing the need for disfiguring treatment of penile tumors in some patients and (2) reducing the number of unnecessary inguinal staging procedures in others. Novel systemic therapies that generate durable responses tested in multi-institutional treatment trials are needed.     

Has anything changed in the quality of continuing education in orthopaedic/trauma surgery? Evaluation 1 year after implementation of a new code of practice for resident training in orthopaedic/trauma surgery in Bavaria

OBJECTIVE: It was the aim of this study to evaluate any changes in the quality of orthopaedic/trauma training 1 year after implementation of the new code of practice for resident training in Bavarian clinics. METHODS: A questionnaire was prepared by the Educational Committee and the Junges Forum of the German Trauma Society and sent to all 120 instructors (and their medical staff) for resident training in Bavaria for general surgery, trauma surgery as well as orthopaedic/trauma surgery on July 26 2005. RESULTS: While 56% of the chairmen claimed to perform a structured, curricular training, only 18% of the residents could verify this. In a similar manner, the majority of chairmen were satisfied with the new code of practice for resident training, while the majority of residents and attendings were not. CONCLUSION: One year after implementation of a new code of practice for resident training in Bavaria, surgical training structures are not well established. There is a large discrepancy in the evaluation of training quality between chairmen and residents. It is therefore imperative to develop recommendations for structuring orthopaedic/trauma training.     

What's new in our understanding of the role of adipokines in rheumatic diseases?

Important advances in our understanding of the relationships between adipokines, inflammation and the immune response have been achieved in the past 10 years. White adipose tissue has emerged as a highly dynamic organ that releases a plethora of immune and inflammatory mediators that are involved in numerous diseases, including not only rheumatic diseases such as rheumatoid arthritis, osteoarthritis and systemic lupus erythematosus, but also cardiovascular and metabolic complications that are frequently observed in rheumatic diseases. Our rapidly growing knowledge of adipokine biology is revealing the complexity of these amazing proteins, thereby redefining white adipose tissue as a key element of the inflammatory and immune response in rheumatic diseases. Adipokines exert potent modulatory actions on target tissues and cells involved in rheumatic disease, including cartilage, synovium, bone and various immune cells. In this Review, we describe the most recent advances in adipokine research in the context of rheumatic diseases, focusing primarily on leptin, adiponectin, visfatin and resistin, and also the potential role of newly identified adipokines such as chemerin, lipocalin 2 and serum amyloid A3.     

What's new in liver surgery in the year 2000?

More than half a century ago, Ton That Tung, then Lortat-Jacob performed the first anatomic hepatectomies, marking the onset of the conquest of liver surgery. Shortly thereafter, a few pioneers took the leap, making the first attempts at total hepatectomy and liver transplantation. Within years, considerable progress was made in hepatobiliary surgery which rapidly became a full-fledged surgery specialty. Techniques were equally improved with new advances in imaging and technology. The last 15 years have been so rich at in the strict sense of the word, little is new in liver surgery in 2000. What has changed is the general perception that liver surgery is entering a new era in the third millennium: high-tech surgery, a surgery that is safe, self-confident, yet aggressive and ambitious, a surgery that is perfectly integrated into increasingly sophisticated and comprehensive therapeutic schemes.     

Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer?

Background

Inadequate anti–factor Xa levels and increased venous thromboembolic events occur in trauma patients receiving standard prophylactic enoxaparin dosing. The aim of this study was to test the hypothesis that higher dosing (40 mg twice daily) would improve peak anti-Xa levels and decrease venous thromboembolism.

Methods

A retrospective review was performed of trauma patients who received prophylactic enoxaparin and peak anti-Xa levels over 27 months. Patients were divided on the basis of dose: group A received 30 mg twice daily, and group B received 40 mg twice daily. Demographics and rates of venous thromboembolism were compared between dose groups and patients with inadequate or adequate anti-Xa levels.

Results

One hundred twenty-four patients were included, 90 in group A and 34 in group B. Demographics were similar, except that patients in group B had a higher mean body weight. Despite this, only 9% of group B patients had inadequate anti-Xa levels, compared with 33% of those in group A (P = .01). Imaging studies were available in 69 patients and revealed 8 venous thromboembolic events (P = NS, group A vs group B) with significantly more venous thromboembolic events occurring in patients with low anti-Xa levels (P = .02).

Conclusions

Although higher dosing of enoxaparin led to improved anti-Xa levels, this did not equate to a statistical decrease in venous thromboembolism.