Criteria for level 1 and level 2 trauma codes: Are pelvic ring injuries undertriaged?

AIM: To determine the association of unstable pelvic ring injuries with trauma code status.METHODS: A retrospective review of all pelvic ring injuries at a single academic center from July 2010 to June 2013 was performed. The trauma registry was used to identify level 1 and level 2 trauma codes for each injury. The computed tomography scans in all patients were classified as stable or unstable using the Abbreviated Injury Scale. Pelvic injury classifications in level 1 and level 2 groups were compared. Patient disposition at discharge in level 1 and level 2 groups were also compared.RESULTS: There were 108 level 1 and 130 level 2 blunt trauma admissions. In the level 1 group, 67% of pelvic injuries were classified as stable fracture patterns and 33% were classified as unstable. In the level 2 group, 62% of pelvic injuries were classified as stable fracture patterns and 38% were classified as unstable. level 1 trauma code was not associated with odds of having an unstable fracture pattern(OR = 0.83, 95%CI: 0.48-1.41, P = 0.485). In the level 1 group with unstable pelvic injuries, 33% were discharged to home, 36% to a rehabilitation facility, and 32% died. In the level 2 group with unstable pelvic injuries, 65% were discharged to home, 31% to a rehabilitation facility, and 4% died. For those with unstable pelvic fractures(n = 85), assignment of a level 2 trauma code was associated with reduced odds of death(OR = 0.07, 95%CI: 0.01-0.35, P = 0.001) as compared to being discharged to home.CONCLUSION: Trauma code level assignment is not correlated with severity of pelvic injury. Because an unstable pelvis can lead to hemodynamic instability, these injuries may be undertriaged.     

Is sympathectomy at T4 level better than at T3 level for treating palmar hyperhidrosis?

PURPOSE: We compared the results from a video-assisted thoracoscopic sympathectomy (VTS) at the T4 denervation level with those from a VTS at the T3 level for the treatment of palmar hyperhydrosis (PH). METHODS: Seventy patients with PH were prospectively followed for VTS at the T3 or T4 denervation levels for 6 months. The end points of this study were: absence of PH, compensatory hyperhydrosis (CH), and quality-of-life assessment. RESULTS: Sixty-seven patients reported a complete resolution of PH after surgery. One failure occurred in the T3 group and 2 in the T4 group. When anhydrosis was obtained, we noticed totally dry hands in 26 patients in the T3 group and 6 patients in the T4 group. The other 27 patients in the T4 group and 8 in the T3 group maintained a small level of sweating and were also considered to be therapeutic successes. At 6 months, 25 patients in the T4 group had some degree of CH (71.42%) and all patients in the T3 group (100%), though the T4 group had a lower degree of severity of CH at the 6-month follow-up (P < 0.05). After the operation, quality of life was improved similarly in both groups. CONCLUSIONS: VTS at either the T3 or T4 level provides an effective treatment for PH. VTS at the T4 level is associated with a less severe form of CH. Despite the occurrence of CH, patients' quality of life is significantly improved following VTS at the T3 or T4 levels. For this reason, the T4 resection can now be used as a treatment for PH.     

Human plasma DNP level after severe brain injury

Objective: To determine the relationship between DNP level after human severe brain injury and hyponatremia as well as isorrhea. Methods: The peripheral venous plasma as control was collected from 8 volunteers. The peripheral venous plasma from 14 severe brain injury patients were collected in the 1,3,7 days after injury. Radioimmunoassay was used to detect the DNP concentration. Meanwhile, daily plasma and urine electrolytes, osmotic pressure as well as 24 h liquid intake and output volume were detected. Results: The normal adult human plasma DNP level was 62. 46 pg/ml±27. 56 pg/ml. In the experimental group, the plasma DNP levels were higher from day 1 to day 3 in 8 of the 14 patients than those in the control group (P1 =0.05, P3 =0.03). Negative fluid balance occurred in 8 patients and hyponatremia in 7 patients. The increase of plasma DNP level was significantly correlated with the development of a negative fluid balance (r = -0.69, P<0.01) and hyponatremia (X2=4.38, P<0.05). Conclusions: The increase of plasma DNP level is accompanied by the enhancement of natriuretic and diuretic responses in severe brain-injured patients, which is associated with the development of a negative fluid balance and hyponatremia after brain injury.     

Radiology residents’ skill level in chest x-ray reading

Rationale and objectives

To evaluate the mean skill level of radiology residents in chest X-ray (CXR) reading, with regard to cognitive mechanisms involved in this task and to investigate for potential factors influencing residents’ skill.

Adjacent level disk disease--is it really a fusion disease?

Adjacent segment degeneration (ASD) is a relatively common phenomenon after spinal fusion surgery. Whether ASD is a consequence of the previous fusion or an individual's predisposition to continued degeneration remains unsolved to date. This article summarizes the existing biomechanical and clinical literature on the causes and clinical impact of ASD, as well as possible risk factors. Further, the theoretical advantage of motion-preserving technologies that aim to preserve the adjacent segment is discussed.     

What is a normal lactate level during cardiopulmonary bypass?

Blood lactate levels during cardiopulmonary bypass are often used to verify adequacy of perfusion. The present investigation aimed to propose a threshold for hyperlactatemia. Blood lactate levels in 5 121 cardiac surgical patients were retrospectively analysed by a review of database records. Hyperlactatemia was defined as a value equal to the 90th percentile of the identified lactate distribution at weaning from cardiopulmonary bypass. Patient demographics, background and outcome statistics were performed stratified on presence of hyperlactatemia. The threshold for hyperlactatemia was found to equal 2 mmol/l. Significant predictors of hyperlactatemia based on logistic regression modelling were age, complex surgery, duration of cardiopulmonary bypass, blood transfusion, acid base level, emergency operations, diabetes, vasoactive intervention, venous-blood-return to the heart-lung machine and renal function. Patients with hyperlactatemia required longer intensive care and postoperative ventilatory support. Complications were more frequent, especially: renal dysfunction, infections, respiratory and circulatory disorders. Hospital mortality was 13.3% compared to an overall level at 2.2%. The threshold for hyperlactatemia during cardiopulmonary bypass attained 2 mmol/l and predicted increased morbidity and mortality.     

Is elevated creatinine level a contraindication to endovascular aneurysm repair?

PURPOSE: It is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI. METHODS: Endovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350). RESULTS: The incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P <.05), and larger contrast volume was associated with an increase in serum Cr (P <.05) during the postoperative period. CONCLUSIONS: EVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents.     

The impact of maintaining normal serum albumin level following living related liver transplantation: does serum albumin level affect the course? A pilot study

Hypoalbuminemia in patients with end-stage liver disease persists for weeks even after liver transplantation. Human albumin is widely used for volume replacement, to increase oncotic pressure, to improve organ function, and to promote wound healing. However, these practices are not evidence-based. We prospectively studied the clinical outcome of 40 patients following living related liver transplantation. Patients were randomized to an albumin group (n=20), where 20% human albumin was administered to maintain serum albumin level>or=3 g/dL, and a control group (n=20), where there was no correction for serum albumin. Hemodynamics and laboratory investigations, fluid administration, blood transfusion, and fluid balance were recorded during the first 5 days in the intensive care unit. Serum albumin level was significantly higher in the albumin group. Heart rate, blood pressure, central venous pressure, and cardiac output did not vary significantly between the groups. There was no significant difference in serum creatinine, creatinine clearance, bilirubin, ALT, AST, prothrombin time, and international normalized ratio between both groups. No significant difference between Tacrolimus level and dose required to maintain therapeutic concentration was noted between both groups. Postoperative course and complications did not vary significantly between both groups. In conclusion, postoperative albumin administration to a target serum albumin>or=3 g/dL does not have additional benefits for the postoperative course in patients scheduled for living related liver transplantation.     

Correlation between sperm DNA 8-Hydroxy-2''''-deoxyguanosine level and semen quality

8-hydroxy-2'-deoxyguanosine (8-OHdG), a typical form ofDNA adducts, is a key molecular biomarker for DNA oxidativedamage. The aim of the present study was to evaluote the correla-tion between the sperm DNA 8-OHdG level and the semen quality.In 52 male infertile patients, the sperm DNA 8-OHdG level wasdetermined by a high performance liquid chromatograph with elec-trochemical detector and the semen quality was examined according     

Does a mid-lumbar block level provide adequate anaesthesia for transurethral prostatectomy?

In this prospective, randomized study, 23 patients having spinal anaesthesia for transurethral prostatectomy (TURP) were evaluated for the adequacy of their block using a visual analog pain score (V4 PS). Each patient with a “standard”(≥T₁₀) block level (n = 5) or “intermediate” (L₁ or T₁₂) block level (n = 5) found the block adequate. Sixty-two percent (8/13) of patients with a “low”-L₃) block level found their block adequate. The VAPS was assessed every five minutes or whenever pain abruptly increased during TURP; an “inadequate block” was defined as a V4 PS ≥ 5 /10 during prostatic resection. Intravesical pressure was monitored and kept <15 mmHg to distinguish between pain from bladder distension and from prostatic resection. “Low” block patients (LBP) who found their block inadequate (n = 5) received supplemental intrathecal local anaesthetic given through a spinal catheter. The subsequent L₁ block level was adequate for TURP. In LBP, who found their block adequate (n = 8), a higher (P < 0.01) VAPS was observed than in patients with a “standard” block level. However, a smaller (P < 0.05) maximum percent decrease in diastolic blood pressure was found in LBPs, than in “intermediate” or “standard” block patients. It is concluded that a spinal block ≥L₁) is adequate during TURP when bladder pressure is monitored and kept low. Mid-lumbar block levels should be reserved for patients in whom the benefit of minimizing haemodynamic changes outweighs the risk of a “less complete” anaesthetic.