Research Pearls: How Do We Establish the Level of Evidence?

Evidence-based medicine (EBM) guidelines were first introduced in 1986 and were defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Level of evidence (LOE) stratifies publications from Level I to Level V and provides the foundation for EBM. Three questions should be asked when an LOE is assigned to a scientific article: (1) What is the research question? (2) What is the study type? and (3) What is the hierarchy of evidence? In cases in which LOE is not appropriate or relevant (basic science and laboratory-based investigations), a clinical relevance statement should be used. Unfortunately, study quality is not assessed by the assigned hierarchy level. LOE and EBM have increased the number of investigations published with better levels of evidence. As authors, reviewers, editors, and publishers, we desire a system that is consistent, effective, and reliable. Fortunately, the system has proven to have all of those attributes with good interobserver and intra-observer values. The increase in investigations with higher LOEs allows for more frequent use of EBM.     

Surgical treatment of calcinosis cutis in the upper extremity

Recent surgical experience with 11 cases of calcinosis cutis has given the authors an opportunity to define the role of surgery in the management of this condition. In scleroderma associated with dermatomyositis, when complications or disability arise from one or more areas of calcinosis, surgery may give significant palliation. Wound healing, although a potential problem, does not constitute a contraindication to operative treatment. Damage to deep structures usually is avoidable, but in some instances is a reasonable trade-off for the benefits obtained. Follow-up has confirmed that surgery is beneficial to patient comfort and function, even in the few patients in whom some calcinosis recurred.     

Research Pearls: Expert Consensus Based Evidence Using the Delphi Method

The evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable. In principle, there are 2 consensus methods for expert opinion available: the nominal group technique and the Delphi method. The nominal group technique is a structured face-to-face meeting facilitating discussion and allows participants to voice their opinions. The key characteristics of the Delphi method are the use of panel experts to obtain data, no face-to-face discussions, the use of sequential questionnaires, the systematic emergence of a concurrent opinion, use of frequency distributions to identify patterns, and the use of at least 2 rounds with feedback between rounds. We should not dismiss the collective experience of our leading experts, and expert consensus-based evidence should be explored as another tool to improve the quality of treatment for our patients.     

Injury and pregnancy

This subject receives very little attention in textbooks and most of the articles in journals report small numbers of injuries of one kind or another. One general review suggests that between 5 and 10 per cent of pregnant women suffer injury, usually with no risk to the pregnancy: for example, the incidence of abortion ascribed to accidental injury is less than 1 in 10,000. Personal and reported experience can be summarized as follows. The baby may be injured during pregnancy or during birth, or may be harmed by the effects or complications of injury to the mother, e.g. Gram-negative septicaemia or hypoxic states. Injuries inflicted on the baby during pregnancy are most often fractures, which affect the skull almost as often as any other bone, and frequently accompany fractures of the mother's pelvis. Gunshot and other penetrating injuries of the child are rare and are not always fatal. Fractures of the maternal pelvis are the most frequent of the major injuries and are serious to viscera and other parts of the body. In some patients deformation of the pelvis can be corrected or prevented by operation, but it is usually best accepted. Rigid internal fixation of fractures of the lower limbs sustained in the later months of pregnancy can make labour much easier for the patient and her attendants. If the effect of injury on pregnancy is usually obvious, the effect of pregnancy on recovery from injury is usually not.     

The importance of middle or long finger realignment in ulnar drift.

Based upon the hypothesis that ulnar drift is the result of a chain reaction starting with a medial shift of the proximal phalanx at the metacarpophalangeal joint and progessing to subluxation of the extensor tendon and finally subluxation of the metacarpophalangeal joint, the author recommends early operative realignment. The extensor tendon is partially divided and a portion passed through the base of the phalanx, the intrinsic tendons are transferred to divided, the junctura tendnium is served, the periosteum is stripped from the neck of the metacarpal, and areas of bony erosions are curetted. In 25 patients with involvement of the middle finger only, alignment was maintained in all over a period of 3 months to 7 years, the average follow-up period being 1.4 years. When deformity was severe and the radical collateral ligament has been disrupted, correction was not always maintained. Early treatment is recommended.     

Avulsion of the gall bladder in blunt abdominal trauma

T raumatic avulsion of the gall bladder, and its subsequent dislodgement into the pelvis has not previously been reported. The case described records severe damage to the biliary system without much damage to other viscera.     

The ureteric orifice: the embryologic key to radiologic status of duplex kidneys.

In this study the ureteric orifice position of duplex ureters in the bladder or urethra of children was correlated with the kidney configuration as determined by x-ray examination and in some by surgical excision and biopsy.A previous study¹ of 51 necropsy speciments of duplex kidneys, ureters, and bladders of neonates, revealed a close correlation between ureteric oreteric orifice position and kidney morphology.This clinical study of children further confirms that the position and type of ureteral orifice act as guides to renal order and disorder in duplex kidneys. A radiographic classification of kidney configurrations was invoked to match and correlate form with orifice position. From this cystoradiographic study, it appears that renal abnormalities occur when ureteric buds arise from faulty locations in the Wolffian duct during embryogenesis.     

Local composite neurovascular island flap for skin cover in pulp loss of the thumb.

A local composite neurovascular island flap to provide stable skin cover with good soft tissue padding and sensibility for extensive pulp loss of the thumb was used in five patients. The island flap included the dorsoradial branches of the radial digital neurovascular bundle of the thumb.     

Endotoxin clearance after intralipid infusion

Healthy 6–8-wk-old New Zealand white rabbits were injected with chromium-chloride- or sodium-chromate-labeled E. coli endotoxin after rapid infusion (10 ml/kg in 1 hr) or slow and repeated infusions (40 ml/kg daily for 7 consecutive days) of 10% Intralipid. Endotoxin clearance rates and RES organ uptakes were determined and the results were compared with those of the controls treated with correspondingly equal volumes of 5% $\text{D}\text{W}$ instead of fat.In the acute experiment, the clearance rates were similar in all animals during the first 15 min following endotoxin injection. After this phase, however, experimental animals had faster endotoxin clearance and eventually higher organ uptakes than the controls. In the chronic experiment, there was no significant difference in endotoxin clearance rates or total and per-gram organ uptakes between experimental and corresponding control animals infused with 5% $\text{D}\text{W}$ instead of fat.Experimental animals, particularly those having received multiple infusions of fat emulsion, showed deposition of polarizable brown pigment inside and outside the reticuloendothelial cells in the liver, spleen, and bone marrow. None of the controls had these pigments in their organs.     

Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Trauma and the cystic meniscus: Review of 500 cases

A review is presented of 500 cases of cystic menisci diagnosed clinically. The distribution by age, sex, side, and site is analysed as is the mode of presentation, history, and type of trauma, as well as locking.

Operative findings in 299 patients are discussed, undamaged menisci being found in 50 per cent.

With a history of trauma (37 per cent) the meniscus was found to be damaged in 59 per cent, without it the incidence was 45 per cent.     

The causes of injuries requiring admission to hospital in the 1970s

One thousand four hundred and seventeen patients admitted to hospital as a result of injury have been investigated as to the aetiology of the injury. The commonest cause of injury was road traffic accidents but there were many other causes including domestic accidents, sport, alcohol, assault, and injuries sustained at work and in the street. Many of these accidents were avoidable and it is suggested that large publicity campaigns to make people aware of the possible hazards they face in their home, at work, on the playground and on the street might be indicated.     

The syndrome of the fracture of the lesser trochanter in adults: a neglected aspect of the trochanteric fracture

The effects of associated fractures of the lesser trochanter were observed in 18 (47.4 per cent) out of 38 patients with trochanteric and subtrochanteric fractures when the lesser trochanter was grossly displaced. This syndrome, comprising mechanical, reflex, post-traumatic, and late features, is a reliable guide to the prognosis of these elderly patients.     

Vertebral anomalies associated with esophageal atresia and tracheoesophageal fistula with reference to the initial operative mortality

In a series of 40 patients with esophageal atresia and tracheoesophageal fistula, the incidence of musculoskeletal anomalies was 45% (18 patients). An extra mesodermal segment was found in 15 patients (13 paired thoracic vertebrae and 13 paired ribs in nine patients; six lumbar vertebrae in 6 patients). The mortality in grade A infants with an extra mesodermal segment was significantly higher than in those infants with a normal spine (p > 0.01). It is suggested that segmentation or abnormal segmentation of the embryo may be important as a cause of esophageal atresia.     

Recurrent intussusception in children.

Twenty-eight children with 35 recurrent intussusceptions were collected and analyzed from a series of 600 intussusceptions over 17 yr. The overall recurrence rate in the entire series was 5% with 11% recurring after hydrostatic barium enema reduction, and 3% after operative reduction. Twenty-three children had one recurrence each, four children had two recurrences, and one child had four recurrent intussusceptions. More than two-thirds of the patients had a recurrence within 6 mo of their first intussusception, and half of these presented earlier and with fewer signs and symptoms than the previous attack had manifested. Twenty-one of 30 recurrences were reduced with barium enema. Sixteen were operated on, reducing nine manually and resecting four others. Only two leading points were found, and in both instances resection was required. All but two of the intussusceptions were ileocolic. The previous mode of reduction of each intussusception did not set a trend for future treatment of recurrent intussusceptions in the same child. While operative reduction diminishes the chances of a recurrent intussusception and ileocolic resection eliminates it, there does not seem to be any indication for surgery as long as barium enema reduction is successful. We have never observed the hydrostatic reduction of an intussusception caused by a leading point.     

Inhibition of Interleukin-10 in the tumor microenvironment can restore mesothelin chimeric antigen receptor T cell activity in pancreatic cancer in vitro

Background

Pancreatic cancer cells are known to shield themselves from immunosurveillance by secreting immune inhibitory cytokines such as Interleukin-10. Using mesothelin, a differentiating antigen that is overexpressed in pancreatic cancer, we assessed the negative effect of the tumor microenvironment on chimeric antigen receptor T cell–based immunotherapy and its reversal via depletion of Interleukin-10.

Spontaneous esophageal rupture in the Newborn

Acute respiratory distress in the newborn may be caused by spontaneous rupture of the esophagus. The diagnosis is suggested by the finding of a tension hydropneumothorax, usually right sided, and is readily confirmed by a contrast swallow. Prompt exploration and repair of the esophagus may be life saving.     

Later Evaluation of Ischemia and Reperfusion by the Pringle Maneuver in Wistar Rats,Demonstrating That Hepatic Lesions Can Be Reversible

Objective

There has been much research on hepatic ischemia and reperfusion by means of short or longer interruption of the portal triad. The aim of this work was to evaluate the mitochondrial respiratory activity and liver histology at 2 different times after the Pringle maneuver.