Fertility preservation after bilateral severe testicular trauma

Dear Editor, Testicular trauma is a frequent acquired cause o fin fertility; being accidents, work injuries and sport activities that are the most common causes of testicular traumas.1＇2 Strangely, the issue of management of serious testicular trauma and fertility preservation has not been studied extensively before, existing only sporadic reports in international literature. Besides, no guidelines exist on fertility preservation in cases of important scrotal trauma when injury may result in irreparable damage to all testicular tissue （torsion of a solitary testis, bilateral synchronous testicular torsion,     

Need for bilateral electroretinography in unilateral trauma

Electroretinography revealed unsuspected night blindness in a patient who had suffered unilateral trauma. This case illustrates the importance of testing both eyes, even when one appears normal.     

Primary bilateral adrenocortical causes of Cushing's syndrome.

Nontumorous primary adrenal causes of Cushing's syndrome are exceedingly rare. Herein we review our results with seven patients in whom there is biochemical evidence of a primary (adrenocorticotropin independent) bilateral adrenal cause of endogenous hypercortisolism. Each patient had low plasma adrenocorticotropin levels. All patients had elevated 24-hour urinary free cortisol levels and 17-hydroxycorticosteroids that were not suppressed by high-dose dexamethasone. Plasma levels of adrenocorticotropin and cortisol were not elevated by ovine corticotropin-releasing factor. No patient had a gradient between petrosal and peripheral adrenocorticotropin levels. No pituitary tumors were detected by magnetic resonance imaging or computed tomography. Five of six patients who underwent iodocholesterol scanning showed bilateral adrenal activity. Computed tomographic and magnetic resonance imaging of the abdomen demonstrated bilateral small adrenal glands in three patients, an adrenal mass in one patient with Carney's complex, and massively enlarged glands in three patients. Each patient underwent bilateral adrenalectomy and was given glucocorticoid and mineralocorticoid replacement. Pathologic examination of four of these bilateral adrenal specimens revealed primary pigmented micronodular adrenocortical disease, with adrenal gland weights between 2.5 and 13.4 gm (mean 5.2 gm). However, the remaining three patients had primary adrenocorticotropin-independent bilateral macronodular adrenocortical disease with adrenal gland weights between 32 and 81 gm (mean 52 gm). Although each of the patients with primary pigmented micronodular adrenocortical disease was cured by bilateral adrenalectomy through a posterior approach, two of the three patients required an anterior approach. We conclude that Cushing's syndrome can arise through two distinct forms of primary bilateral adrenal cortical disease. Computed tomography is important in evaluation of these patients because the size of the adrenal glands influences the surgical approach.     

Isolated bilateral blunt renal trauma with pelviureteric disruption

Pelviureteric junction disruption with contralateral renal fracture occurred without injury to other organs as a result of vehicular trauma. The problems of treating this type of case are described.     

Frequency and causes of seizure among hospitalized burned children

Methods

In this cross-sectional retrospective study, frequency, type, time of occurrence and atiology of seizures in children with burn was investigated. All cases were under 18 years and were hospitalized in Shahid Motahari Burns Hospital during 2006–2011. Extracted data from patients’ medical records was reviewed and statistically analyzed.

Results

Among 1103 patients, 69 (6.2%) had seizures, more frequently in the first 24 h following burn. Thermal burn, especially with boiling water was the cause of burn in most of the children. Seizures occurred more commonly in children less than 3 years old and was generalized (tonic–clonic). Seizure was found to be primarily associated with febrile seizure, while hyponatremia was diagnosed as the second cause. Previous seizure history and seizure with unknown cause were identified as other etiologies.This paper summarizes the key information about seizure following burn, which health professionals, especially those in burn centers, should be aware. However, since this study was single-center more investigations in other centers are needed.     

Occult bilateral acetabular fractures associated with high-energy trauma and osteoporosis

Acetabular fractures that are radiographically occult are associated with osteoporosis, low-energy trauma, and advanced age. We present a case of bilateral occult acetabular fractures in a 65-year-old woman who presented with an open tibia-fibula fracture and compartment syndrome and thoracolumbar spine fractures sustained in a motor vehicle accident. Initial radiographs of the pelvis and a pelvic CT scan did not show any bony injuries when the films were reviewed prospectively. At 6 weeks after injury, a CT scan and plain radiographs showed bilateral healing transverse acetabular fractures with acetabular protrusio on the left. At most recent follow-up, the patient had posttraumatic hip arthritis with moderate protrusio on the left and was ambulating with a cane. Total hip arthroplasty is anticipated in the future.     

Survival of trauma patients with coma and bilateral fixed dilated pupils

Background

Survival of patients with severe trauma presenting with Glasgow Coma Score (GCS) 3 and bilateral fixed dilated pupils is uncertain. Pre-hospital management of these patients affects the true measurement of the GCS and other factors may affect pupillary status.

Patients and methods

A retrospective review was undertaken of all patients who were classified GCS 3 and had bilateral fixed dilated pupils on admission to a Level 1 Adult Trauma Centre between July 2001 and March 2005. Pre-hospital assessment, hospital interventions and outcomes were determined.

Results

Ninety-three patients fulfilled the criteria for inclusion into the study. There were 6 survivors who were all less than 28 years of age, had at least one GCS score above 3 in the pre-hospital phase and were more likely to have had an evacuable mass lesion on CT brain scan and undergo craniotomy. Of the 6 surviving patients, none had significant thoracoabdominal injuries. Four of the survivors had Glasgow Outcome Score (GOS) of 4 or 5. Time to hospital, mechanism of injury and pre-hospital haemodynamic parameters had no significant effect on survival. Of the 57 patients who were GCS 3 at the scene of the accident, post-basic resuscitation and on admission, none survived.

Conclusion

Pre-hospital GCS scores, prior to the effects of intubation, sedation and paralysis should be given more attention when assessing prognosis in patients who are GCS 3 on admission. Trauma patients with GCS 3 persisting from the scene with bilaterally fixed dilated pupils have no appreciable chance of survival. Further interventions such as ICU admission and surgery may not be warranted. Physicians may need to consider stopping treatment and discussing organ donation.     

Incidence and causes of mortality following acute orthopaedic and trauma admissions

PURPOSE: To analyse the incidence and causes of mortality of orthopaedic and trauma patients. METHODS: Between March 1995 and October 2000, there were 594 (404 females) in-patient deaths (2.8%) with a mean age of 82.14 years (range, 21-102 years) out of 21,122 acute admissions. The cause of death and details of the acute episode were collected from the hospital records, death certificates and postmortem examinations. Data collected were computerised and analysed using the Astute statistical package, University of Leeds. RESULTS: The most common primary diagnosis on admission was fracture neck of femur 392 (69.1%; P = 0.001). In total, 443 (78.1%) patients underwent surgical intervention of their injuries prior to mortality with 21 patients (4.7%) dying on the same day of the operation. The mean number of days between the initial surgical intervention and death was 22.3 days (range, 0-154 days). Of the patients who were treated non-operatively, 124 died due to poor medical condition (4 [3.2%] died within 24 h, 66 [51.6%] died within the first week and the rest died thereafter). In the death certificate, the most common primary cause of death recorded in the group of patients of 64 years of age and below was cancer followed by multi-organ failure. In the age group of 65 years and above, the most common primary cause of mortality was pneumonia followed by heart failure and myocardial infarction. CONCLUSIONS: In orthopaedic and trauma patients below the age of 65 years, the most common cause of death appears to be cancer followed by multiple system organ failure; in the elderly, pneumonia predominates followed by heart failure and myocardial infarction. Proximal femoral fractures accounted for 70% of the deaths.     

肝外伤死亡原因分析

近年来，国内外学者对肝外伤特别是严重肝外伤处理积累了许多成功的经验。创伤处理新概念的确立和治疗方法的改进已使Ⅲ、Ⅳ级肝损伤的死亡率降至10％以下，但严重肝外伤所导致的死亡在基层医院死亡病例中仍占据较高比例。因此，分析肝外伤死亡原因，有助于在抢救肝外伤病人时采取更为有效的措施，从而提高救治成功率。     

Closed cervical spine trauma associated with bilateral vertebral artery injuries

Bilateral vertebral artery injuries in closed cervical spine injuries are uncommon, but early recognition and treatment are important to prevent neurological deterioration. A case of bilateral vertebral injuries in a 35-year-old motor vehicle accident victim is presented, and the current literature is reviewed.     

Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome

HYPOTHESIS: Normal resuscitation (oxygen delivery index [DO2I] >/=500 mL/min per square meter), compared with supranormal trauma resuscitation (DO2I >/=600 mL/min per square meter), requires less crystalloid volume, thus decreasing the incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). DESIGN: Retrospective analysis of a prospective database. SETTING: Twenty-bed intensive care unit (ICU) in a regional level I trauma center. PATIENTS: Patients with major trauma (injury severity score >15, initial base deficit >/=6 mEq/L, or need for >/=6 units of packed red blood cells in the first 12 hours) or age 65 years or older with any 2 of the previous criteria. INTERVENTIONS: Shock/trauma resuscitation protocol: pulmonary artery catheter, gastric tonometry, urinary bladder pressure measurements, lactated Ringer infusion, packed red blood cell transfusion, and moderate inotrope support, as needed, in that sequence, to attain and maintain a DO2I greater than or equal to 600 mL/min per m2 (16 months, ending January 1, 2001, n = 85) or a DO2I greater than or equal to 500 mL/min per square meter (16 months, starting January 1, 2001, n = 71) for the first 24 hours in the ICU.Main Outcome Measures: Lactated Ringer infusion volume (liters) at ICU admission, gastric partial carbon dioxide minus end-tidal carbon dioxide(GAPCO2), IAH (urinary bladder pressure measurements >20 mm Hg), ACS (urinary bladder pressure measurements >25 mm Hg with organ dysfunction), multiple organ failure, and mortality. RESULTS: Demographics, injury severity, and shock severity parameters were similar in both groups. The supranormal resuscitation group required more lactated Ringer infusion volume in the first 24 hours in the ICU (mean +/- SD, 13 +/- 2 vs 7 +/- 1 L; P<.05) and had higher GAPCO2 (16 +/- 2 vs 7 +/- 1 mm Hg; P<.05). In the supranormal group, IAH (42% vs 20%; P<.05) and ACS (16% vs 8%; P<.05) were more frequent. The conventional trauma outcomes, such as multiple organ failure (22% vs 9%; P<.05) and mortality (27% vs 11%; P<.05) were less favorable in the supranormal resuscitation group. CONCLUSION: Supranormal resuscitation, compared with normal resuscitation, was associated with more lactated Ringer infusion, decreased intestinal perfusion (higher GAPCO2), and an increased incidence of IAH, ACS, multiple organ failure, and death.     

Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types

Summary Shunt complications and revisions are common in hydrocephalic patients treated with a ventriculo-atrial or a ventriculo-peritoneal shunt. The reported revision rate differs very much but the rate of revision is close to 50% in many papers. Data from 884 hydrocephalic patients treated with various shunt types in the period 1958–1989 were recorded retrospectively in order to evaluate the frequency of revision for various shunt types and secondly to analyse the specific reasons for the shunt revisions.The rate of shunt revision was 45%. The Pudenz shunt was revised more often (62%) than the remaining shunt types. The Hakim and the Orbis-Sigma shunts had fewer revisions (35% and 27%, respectively) than the other observed shunt types. A defect of or an obstruction in the ventricular catheters was a frequent cause of revision followed by a defect or an obstruction of the distal catheter, a displacement of the distal catheter and an acute infection. Because of the higher rate of revision for the Pudenz shunt the rate of the above mentioned specific complications is also higher in most of the subgroups for that specific shunt type. Driven by these experiences it is reasonable to seek to develop and introduce new shunt types in an attempt to reduce the complication rate.