The Benefit of Multislice Computed Tomography in the Emergency Room Management of Polytraumatized Patients

Abstract Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice computed tomography (MSCT) is a quick and reliable method for the initial diagnostic evaluation. CT provides more detailed and more consistent information than conventional radiography and it has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen, and pelvis during one single examination. The CT suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiologic investigations.Since polytrauma management is based on a multidisciplinary approach that is characterized by a coordinated interaction between trauma surgeons, anesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.     

穿透性心脏损伤急诊室剖胸五例穿透性心脏损伤急诊室剖胸五例

目的探讨在急诊室剖胸对危急心脏穿透伤的疗效。方法在急诊室紧急开胸５例，４例濒于死亡，１例已无生命体征；火器伤２例，锐器伤３例；心脏压塞型２例，失血休克型３例。结果全组死亡３例，存活２例（２／５）；火器伤２例均无存活（０／２），锐器伤２例存活（２／３）；压塞型１例存活（１／２），失血休克型１例存活（１／３）。结论急诊室剖胸是救治危急心脏穿透伤的有效手段，濒于死亡的心脏穿透伤特别是锐器伤部分可能获救     

The Benefit of Multislice CT in the Emergency Room Management of Polytraumatized Patients

The early treatment of polytraumatized patients needs an effective and standardized approach. Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice-CT (MSCT) is a quick and reliable method for the initial diagnostic evaluation. Computed tomography provides more detailed and more consistent information than conventional radiography. It has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen and pelvis during one single examination. The CT-suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiological investigations.

Since polytrauma management is based on a multidisciplinary approach characterized by a coordinated interaction between trauma surgeons, anaesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.     

1岁以内婴儿先心病伴肺高压的急诊手术

我院自１９８９年８月至１９９４年１２月共收治１岁以内婴儿先心病伴肺高压１１例，年龄平均５．７月±０．８，体重平均在５．２公斤±０．６，所有病例术前均有反复肺部感染及难以控制的顽固性心衰，均在全麻体外循环下行一期缺损修补的急诊手术，其中８例采用深低温停循环方法，手术效果满意，术后死亡１例。本文着重对急诊手术时机和手术方法的选择以及对这类病儿术后肺高压的处理进行了讨论。     

The Fate of Morbidly Obese Patients With Joint Pain: A Retrospective Study of Patient Outcomes

BackgroundThe number of obese patients seeking a total joint arthroplasty (TJA) continues to increase. Weight loss is often recommended to treat joint pain and reduce risks associated with TJA. We sought to determine the effectiveness of an orthopedic surgeon’s recommendation to lose weight.MethodsWe identified morbidly obese (body mass index (BMI) 40-49.9 kg/m²) and super obese (BMI ≥50 kg/m²) patients with hip or knee osteoarthritis. Patients with less than 3-month follow-up were excluded. Patient characteristics (age, gender, BMI, comorbidities), disease characteristics (joint affected, radiographic osteoarthritis grading), and treatments were recorded. Clinically meaningful weight loss was defined as weight loss greater than 5%.ResultsTwo hundred thirty morbid and 50 super obese patients were identified. Super obese patients were more likely to be referred to weight management (52.0% vs 21.7%, P < .001) and were less likely to receive TJA (20.0% vs 41.7%, P = .004). Each 1 kg/m² increase in BMI decreased the odds of TJA by 10.9% (odds ratio = 0.891, 95% confidence interval: 0.833-0.953, P = .001). Forty (23.0%) of the nonoperatively treated patients achieved clinically meaningful weight loss, and 19 (17.9%) patients who underwent TJA lost weight before surgery. After surgery, the number of patients who achieved a clinically meaningful weight loss grew to 32 (30.2%).ConclusionIn morbid and super obese patients, increasing BMI reduces the likelihood that a patient will receive TJA, and when counseled by their orthopedic surgeon, few patients participate in weight-loss programs or are otherwise able to lose weight. Weight loss is an inconsistently modifiable risk factor for joint replacement surgery.     

Out-of-Hospital Cardiopulmonary Arrest Due to Penetrating Cardiac Injury Treated by Percutaneous Cardiopulmonary Support in the Emergency Room: Report of a Case

Penetrating cardiac injury tends to generally be repaired without cardiopulmonary bypass in the operating room. We herein report the case of penetrating cardiac injury repaired using percutaneous cardiopulmonary support in an emergency room. A 57-year-old man attempted suicide by stabbing himself in the left anterior chest with a knife. Although the patient suffered cardiopulmonary arrest for 7 min in the ambulance, spontaneous circulation was restored following pericardiotomy through emergency left thoracotomy in the emergency room. To prevent coronary artery injury and control the massive bleeding, percutaneous cardiopulmonary support was instituted without systemic heparinization and the cardiac injury was repaired in the emergency room. The patient was then transferred to another hospital on day 46 for further rehabilitation. Percutaneous cardiopulmonary support might be helpful for treating critical patients in an emergency room, even in the case of trauma patients.     

Patterns of Skin Flowmotion in the Lower Limbs of Patients with Chronic Critical Limb Ischaemia (CLI) and Oedema

OBJECTIVE: To study flowmotion (FM) in lower limbs with critical limb ischaemia (CLI) and oedema and to elucidate FM patterns when skin viability is threatened. MATERIAL AND METHODS: Fourteen patients with unilateral CLI and oedema and two control groups were included - one consisting of 10 healthy participants and the other nine patients with unilateral CLI without oedema. Laser Doppler was used to evaluate the foot skin microcirculation simultaneously at four different areas, with the limbs in supine and dependent position. FM was expressed using fast Fourier transformation (FFT) as low frequency (LF) and high frequency (HF) waves and their respective FFT-powers. RESULTS: All patients with CLI, both with and without oedema, showed HF waves in both diseased and contralateral limbs. These were absent in healthy controls. There were no regional differences in frequency in the critically ischaemic feet (with and without oedema) and between ischaemic and their contralateral feet. Changing the position of ischaemic limbs from supine to dependency had no significant effect on the frequency, while a significant increase of the median FFT-powers of LF and HF waves at the pulp of the first toe was observed. This manoeuvre resulted in decrease of the median FFT-powers of LF in healthy controls. CONCLUSIONS: HF waves are associated with CLI. Ischaemia also appears to influence the FFT-power of each frequency domain. Ischaemic oedema does not seem to affect the pattern of FM in the foot of patients with CLI.     

Analysis of the Correlation of Plasma NO and ET-1 Levels in Rats With Acute Mesenteric Ischemia

Mesenteric ischemia is a devastating disease process that frequently challenges clinicians. To enhance the early diagnosis of gut ischemia and judgment of its severity, it may be helpful to detect the unusual existence or increase in biomarkers in the body fluid. The aim of the present study was to evaluate the correlation of plasma nitric oxide (NO) and endothelin-1 (ET-1) levels to mesenteric ischemia using an animal model. Acute mesenteric ischemia (AMI) was produced experimentally by occlusion of the mesenteric vessels in the terminal ileum by the tenting of a thread. The determination of plasma NO and ET-1 levels were obtained before operation (T0, baseline value), and at 10 (T10), 20 (T20), 30 (T30), and 60 (T60) min after the creation of AMI. Sham-operated rats served as controls. After 30 min of experiments, the plasma NO and ET-1 levels were significantly higher in the AMI group than in the control group (both p <. 01). Both the plasma NO and ET-1 levels in AMI group increased significantly after 30 min of ischemia (both p <. 001 vs. respective baseline value), and they were 60% and 84% above the baseline value, respectively. In addition, ischemic intestinal injury was confirmed by the significantly elevated histological scores in the AMI group after 60 min of ischemia (p <. 001). Our preliminary results suggest the possibility of important insights regarding NO and ET-1 changes into the mechanism of pathogenesis in AMI in rats. The increases in plasma NO and ET-1 levels may potentially be noninvasive biomarkers for the early detection of this disease.     

The Hematocrit Affects the Volume of Plasma Treated With Coupled Plasma Filtration and Adsorption With Predilution

Coupled plasma filtration and adsorption (CPFA) is an extracorporeal blood purification technique proposed for the treatment of septic‐shock. By removing pro‐ and anti‐inflammatory mediators from plasma, CPFA is supposed to have a therapeutic effect on the abnormal inflammatory response seen in this condition. Recently, blood predilution with citrate solution has been adopted to prevent clotting in the CPFA circuit—one of the main problems of the technique. Taking into account the patient's hematocrit, we worked out a formula for the volume of plasma effectively treated by CPFA after predilution. Neglecting this effect, as is commonly done, introduces significant distortions in the estimation of the volume, possibly causing under‐treatment. The distortion is stronger when the hematocrit and the predilution fraction are large and weaker when both values shrink. By correctly indicating the daily dose of plasma adsorption received by patients, this formula is essential for assessing the therapeutic efficacy of CPFA and, subsequently, establishing its optimal doses.     

In the Experimental Model of Acute Mesenteric Ischemia,The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment

ABSTRACT

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.     

Comparison of Kidney Transplantation Results From the Same Deceased Donor Between Patients With the First Transplantation and Retransplanted Patients

Background

It has been determined that there are about 25% patients with renal allograft failure on the waiting lists.

Mobility of the First Ray in Patients With or Without Hallux Valgus Deformity: Systematic Review and Meta-Analysis

The hypermobility theory of the first ray is the reason for the popularization of procedures such as the modified Lapidus procedure involving arthrodesis of the first tarsal–metatarsal joint for correction of hallux valgus deformity. Although many studies have involved motion of the first ray in hallux valgus patients, the presence and clinical significance of hypermobility in the first ray remains controversial. We performed a systematic review and meta-analysis to evaluate the difference in the first ray range of motion between patients with or without hallux valgus deformity. The databases used for the present review included Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that had evaluated the motion of the first ray in patients with or without hallux valgus. After screening for inclusion and exclusion criteria, we identified 3 studies that were relevant to our study question. All 3 studies showed more first ray motion in the hallux valgus group. Our quantitative synthesis showed a mean difference in the range of motion of the first ray of 3.62 mm (95% confidence interval 2.26 to 4.98) between those with and without hallux valgus deformity. Thus, we found statistically significantly increased first ray motion in patients with hallux valgus deformity compared with those without hallux valgus deformity. However, the clinical significance of this small amount of increased sagittal plane motion as a response to or a cause of hallux valgus remains unanswered.     

The Prognostic Importance of Tumor Mitotic Rate Confirmed in 1317 Patients With Primary Cutaneous Melanoma and Long Follow-Up

Background: The late Dr. Vincent McGovern (1915 to 1983) was an international authority on melanoma pathology and one of the first to suggest that assessment of tumor mitotic rate (TMR) might provide useful prognostic information. Data for a large cohort of patients, now with extended follow-up, whose tumors had been assessed by Dr. McGovern were analyzed to reassess the independent prognostic value of TMR in primary localized, cutaneous melanoma.Methods: Information was extracted from the Sydney Melanoma Unit database for 1317 patients treated between 1957 and 1982 for whom there was complete clinical information and whose primary lesion pathology, which included tumor thickness, ulcerative state, and TMR, had been assessed by Dr. McGovern. All these assessments were made according to the recommendations of the Eighth International Pigment Cell Conference, held in Sydney in 1972 under the auspices of the International Union Against Cancer. Factors predicting melanoma-specific survival were analyzed with the Cox proportional hazards regression model.Results: Stage, according to the recently revised American Joint Committee on Cancer Staging System (which is based on tumor thickness and ulceration) was the most predictive factor for survival (P < .0001). This was followed by primary lesion site (P < .0001), patient age (P = .0005), and TMR (P = .008).Conclusions: TMR was confirmed to be an important independent predictor of survival of patients with primary cutaneous melanoma. However, its predictive value was less than it was when assessed according to the 1982 revisions of the 1972 TMR recommendations.Died December 30, 1983